Hywel Dda Health Board Listening and Engagement

Home , Begelly, Blaenrheidol, Ceulanamaesmawr, Christine Gwyther, Llangwyryfon, Melindwr

YOUR HEALTH, YOUR FUTURE

Hywel Dda Health Board’s

Listening and Engagement Process

Report of Findings for

Opinion Research Services July 2012

YOUR HEALTH, YOUR FUTURE

Hywel Dda Health Board’s Listening and Engagement Process

Report of Findings for

Opinion Research Services The Strand  Swansea  SA1 1AF 01792 535300 | [email protected] | www.ors.org.uk

As with all our studies, findings from this survey are subject to Opinion Research Services’ Standard Terms and Conditions of Contract. Any press release or publication of the findings of this survey requires the advance approval of ORS. Such approval will only be refused on the grounds of inaccuracy or misrepresentation

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Contents

1. Introduction ...... 9 Overview of the Listening and Engagement Process ...... 9 Challenges and Changes ...... 9 The Commission ...... 9 Accountability ...... 10 Interim Report ...... 11

2. Stakeholder Questionnaire ...... 12 Overview of Findings ...... 12 Summary of Key Findings ...... 12 Stakeholder Questionnaire ...... 13 Questionnaire Responses ...... 14 Respondent Profile ...... 14 Listening and Engagement Questionnaire Results ...... 18 Care Closer to Home ...... 19 Quality and Safety of Services ...... 21 Ageing Population ...... 23 Specialised Services ...... 25 Access ...... 28 Transport ...... 31 Making Every Penny Count ...... 33 Information ...... 35 Further Comments about Service Areas ...... 37 Summary information – Significance and Freetext Comments ...... 38

3. Deliberative Meetings (i) ...... 40 Focus Groups with members of the public ...... 40 Introduction ...... 40 Summary of Key Findings ...... 41 Listening and Engagement Process ...... 42 Views on Current Service Provision ...... 43 Introduction ...... 43 Health Service Management ...... 43 Staffing ...... 44

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Standards ...... 45 HDdHB’s Guarantees and Aims ...... 45 Distance (particularly in relation to Accident and Emergency Services) ...... 45 Specialisation and Centres of Excellence ...... 49 Care Closer to Home ...... 53 GP and Out of Hours Services ...... 55

4. Deliberative Meetings (ii) ...... 57 Focus Groups with Members of Staff ...... 57 Overall Summary ...... 57 Staff Focus Groups and Discussion Agenda ...... 58 Current Services...... 59 Recruitment Difficulties ...... 61 Centres of Excellence ...... 63 Accident and Emergency Centres ...... 67 Care Close to Home ...... 69 The Problem of Demand...... 73 Listening and Engagement Process ...... 74

5. Submissions...... 77 Stakeholder Submissions - Selected Summaries ...... 77 Introduction ...... 77 Hywel Dda Community Health Council, Pembrokeshire Locality ...... 78 Ceredigion GPs’ Forum ...... 79 Ystwyth Medical Group (YMG) ...... 80 Ceredigion Local Service Board (LSB) ...... 81 Ceredigion Voluntary Sector Representatives on the CHC ...... 81 Three Ceredigion County Councillors (on the Ceredigion CHC) ...... 81 Ceredigion County Partnership Forum – staff side representatives ...... 82 HDdHB Partnership Forum – staff side representatives ...... 82 Welsh NHS Confederation ...... 83 Angela Burns, AM ...... 83 Paul Davies, AM ...... 84 Elin Jones, AM ...... 84 Stephen Crabb, MP ...... 84 Simon Hart MP ...... 85 Elfyn Llwyd, MP ...... 85 Save Bronglais Campaign – letters by County Cllrs J Michael Williams and Sylvia Rowlands ...... 85 Save Withybush Action Team (SWAT) ...... 86

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Committee for the Improvement of Hospital Services (CIHS-Sosppan) ...... 87 Town and Community Council submissions ...... 90 Ceredigion, Gwynedd and Powys ...... 91 Pembrokeshire...... 92 Carmarthenshire ...... 92 Voluntary, community group and other organisation submissions ...... 93 Residents’ submissions ...... 95 Staff and GP submissions ...... 97

6. Petitions ...... 98 Expressions of Concern ...... 98 Introduction ...... 98 Petitions about Prince Philip Hospital ...... 99 Petitions about Bronglais Hospital ...... 101 Petitions about the Temporary Closure of Minor Injuries Units ...... 103 Tenby Cottage Hospital ...... 103 Petition to Keep the Minor Injuries Units at South Pembrokeshire and Tenby Open ...... 103 Pre-completed Questionnaires ...... 103 The Need for Interpretation ...... 105

7. Schedule of Listening and Engagement Activities ...... 106 Introduction ...... 106 Meet the Health Board Sessions and Public Forums ...... 106 General Themes and Arguments ...... 107 Llanelli ...... 108 Aberystwyth...... 108 Machynlleth and Llanidloes ...... 109 Complete Schedule of Key meetings ...... 110 Staff Engagement and Communication Activities ...... 116 Staff Engagement and Communication Activity ...... 116 Key Stakeholder Engagement and Communication Activity ...... 122 Political Engagement Events and Key Meetings ...... 128 Political Engagement activity ...... 128 Details of media activity ...... 130 Distribution List – Paper Copies ...... 137 Distribution List - Electronic copies of the Discussion Document and Questionnaires sent to the following across Carmarthenshire, Ceredigion and Pembrokeshire: ...... 138

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Table of Figures

Figure 1: Age – All individual respondents ...... 16 Figure 2: Gender – All individual respondents ...... 16 Figure 3: Ethnic Origin – All individual respondents ...... 16 Figure 4: Longstanding Illness/Disability – All individual respondents ...... 16 Figure 5: NHS Employee – All individual respondents ...... 16 Figure 6: Urban/Rural – All individual respondents that provided a postcode ...... 16 Figure 7: Responses mapped by area, with shaded zones depicting 5km, 10km, 20km and 50km from named General Hospital – All individual respondents that provided a postcode ...... 17 Figure 8: Nearest Main District General Hospital – All individual respondents that provided a postcode ...... 17 Figure 9: Distance to Nearest Main District General Hospital – All individual respondents that provided a postcode ...... 17 Figure 10: To what extent do you agree or disagree with this vision? ...... 19 Figure 11: To what extent do you agree or disagree with this vision? Key Themes Care Closer to Home ...... 19 Figure 12: To what extent do you agree or disagree with this vision - Care Closer to Home? Demographic sub-group analysi ...... 20 Figure 13: To what extent do you agree or disagree with this principle? ...... 21 Figure 14: To what extent do you agree or disagree with this principle? Key Themes Quality and Safety of Services ...... 21 Figure 15: To what extent do you agree or disagree with this principle - Quality and Safety of Services? Demographic sub-group analysis ...... 22 Figure 16: To what extent do you agree or disagree that service planning should treat this as a key priority?...... 23 Figure 17: To what extent do you agree or disagree that service planning should treat this as a key priority? Key Themes Ageing Population ...... 23 Figure 18: To what extent do you agree or disagree that service planning should treat the Ageing Population as a key priority? Demographic sub-group analysis ...... 24 Figure 19: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? ...... 25 Figure 20: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Key Themes ...... 25 Figure 21: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Demographic sub-group analysis ...... 26 Figure 22: Agreement with specialising some services into fewer, fully equipped centres mapped by nearest main general hospital ...... 27

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Figure 23: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Response by distance to nearest main district general hospital ...... 27 Figure 24: Access: To what extent do you agree or disagree that this is reasonable in principle? ...... 28 Figure 25: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Key Themes – Access ...... 28 Figure 26: Access: To what extent do you agree or disagree that this is reasonable in principle? Demographic sub-group analysis ...... 29 Figure 27: Access: Agreement with this being a reasonable in principle mapped by nearest main district general hospital ...... 30 Figure 28: Access: To what extent do you agree or disagree that this is reasonable in principle? Response by distance to nearest main district general hospital...... 30 Figure 29: To what extent do you agree or disagree that transport services need to be improved? ...... 31 Figure 30: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Transport Service Need to be Improved...... 31 Figure 31: To what extent do you agree or disagree that transport services need to be improved? Demographic sub-group analysis ...... 32 Figure 32: To what extent do you agree or disagree that the Health Board should make the best use of scarce resources?...... 33 Figure 33: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Making the Best Use of Scarce Resources ...... 33 Figure 34: To what extent do you agree or disagree that the Health Board should make the best use of scarce resources? Demographic sub-group analysis ...... 34 Figure 35: A range of information about Your Health Your Future has been made available for the listening and engagement process. Please indicate any information you may have read/seen ...... 35 Figure 36: Thinking about 'Your Health Your Future' to what extent do you agree or disagree that it was… ...... 36 Figure 37: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Clarity and Fairness of Information ...... 36 Figure 38: Further comments about service areas ...... 37 Figure 39: Do you agree or disagree with...? Demographic sub-group analysis...... 38 Figure 40: Major Themes Throughout Overall Questionnaire Response ...... 39

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

The ORS Project Team

Project Design, Management and Reporting

Dale Hall Jonathan Lee Kester Holmes Kelly Lock Claire Thomas Hannah Champion

Fieldwork Management

Kirsty Millbank Leanne Hurlow Data Services

Lindsey Carter Leanne Hurlow Data Analysis

Richard Harris Joe Marchant Jonathan Jones Neil Rowlands Hugo Marchant

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

1. Introduction Overview of the Listening and Engagement Process

Challenges and Changes

1.1 ‘Together for Health’ was published by the Minister for Health and Social Services in November 2011 to offer a five-year vision in the context of the challenges facing the health service in Wales. The document declares that Health Boards need to change to provide the very best quality of services for their population in the future:

Standing still is not an option…I believe that no change is not an option…real change is necessary and long overdue. Lesley Griffiths, Minister for Health and Social Services.

1.2 Hywel Dda Health Board faces particular challenges, including:

An ageing population with increasing demands for care

Health inequalities – in which the health of some groups has not improved as much as others

Difficulties in recruiting and retaining sufficient well qualified clinical staff for some services

Sustaining excellent and safe medical care across a large rural area with dispersed communities

Managing services effectively within a limited budget.

1.3 Recognising these challenges, HDdHB is committed to maintaining four main hospitals (at Bronglais, Glangwili, Prince Philip and Withybush) while aiming for safer services, improved patient experiences and treatment outcomes, and value for money from its NHS budget. Within this framework of relative continuity, the Board has embarked upon a major review of its services – beginning with an extensive listening and engagement exercise which will eventually inform draft proposals for changes to some services, which will be subject to further formal Consultation.

1.4 This overall aim of the listening and engagement process was to better inform the Board by providing opportunities for staff, stakeholders and the public to express their ideas about a wide range of health issues in primary and secondary care. The listening and engagement period was originally planned to run from 19th December 2011 until 31st March 2012, but the Board extended it to 30th April 2012 in order to allow more time for public and stakeholder participation.

The Commission

1.5 In the above context, the HDdHB appointed ORS to report on its own listening and engagement activities and also to undertake independent studies of public and stakeholder opinions across Hywel Dda. During the listening and engagement period, ORS has:

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Provided independent advice Developed a template for HDdHB to capture feedback at its public events Reported responses to on-line and paper questionnaires (designed by HDdHB) Recruited, facilitated and reported seven deliberative focus groups with randomly selected members of the public across the locality areas Facilitated and reported a series of staff focus groups with clinicians, doctors, nurses and ancillary staff Analysed a wide range of written submissions from members of the public, voluntary sector and professional organisations, and politicians Attended some public meetings chaired and organised by HDdHB Provided a sequence of interim reports (as well as this document) so that the Board could review the findings on a developing basis.

1.6 In addition to all these activities, HDdHB conducted many meetings with staff and other stakeholder groups as well as twelve important public listening and engagement events, some of which were attended by very large numbers of people. Very much in summary, the main other aspects of HDdHB’s extensive listening and engagement activities were: Distribution of a DVD information pack to all households in the Board area Publicising the engagement activities in the local media Briefings and frequent responses to the press Meetings and briefings with a wide range of organisations including Community Health Councils, Local Authorities, Local Service Boards, Community and Voluntary organisations Briefings to Members of Parliament and Assembly Members from the three main and neighbouring counties Multiple briefings and road-shows to staff and health care professionals Twelve lengthy public drop-in meetings across the seven localities.

1.7 Above all, HDdHB publicised its listening and engagement process widely, and it was frequently and extensively reported in the local press. There can be no doubt that the relevant communities and stakeholders had many chances to take part in the process by making their views known; and the following report will show that many of them did so.

Accountability

1.8 By running such an extensive listening and engagement process in advance of formulating and consulting on its eventual draft proposals, HDdHB has recognised the importance of giving the public and stakeholders the opportunity to influence the evolution of its thinking at a very early stage. The process has been conscientious and proportional to the importance and contraversiality of the issues: in our opinion, the HDdHB has sought to be open, accessible and fair to those wishing to express their views.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

1.9 There have been some understandable criticisms of some aspects of the questionnaires used, but the listening and engagement process overall has been substantial and open – particularly in explaining the Board’s initial thinking, listening to so many responses through a wide range of routes, and in extending the consultation period to enable more people to share their views.

1.10 Accountability means that public authorities should give an account of their plans and take into account public views, but it does not mean that majority views expressed in consultations should automatically decide public policy. Listening and engagement processes, and even formal consultations, are not referenda: they should inform, but not displace, professional and political judgement, which have to assess the cogency of the views expressed.

Interim Report

1.11 This document is a full report of the main elements of the listening and engagement process undertaken by ORS – namely the: Responses to the questionnaires Seven focus groups with members of the public Nine focus group with members of staff

Submissions from a range of interested parties including:

Key stakeholders

Town and Community Councils

Voluntary and community groups and other organisations

Residents

Staff

Petitions

1.12 This document also includes a full schedule of events undertaken in the listening and engagement process.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2. Stakeholder Questionnaire Overview of Findings

2.1 As part of the Your Health Your Future Listening and Engagement process, a stakeholder questionnaire covering all aspects of the proposals was available to be completed online during the engagement period, and paper copies were also available. The questionnaire included questions on the following key topics: » Care Closer to Home » Quality and Safety of Services » Ageing Population » Specialised Services » Access » Transport » Making Every Penny Count » Information » Service Areas

Summary of Key Findings

2.2 Nine out of ten respondents had either seen or read at least some of the ‘Your Health Your Future’ information. The top three information sources were leaflets (46%), the media (41%) and the DVD (40%).

2.3 Of those respondents that had seen or heard information about ‘Your Health Your Future’: » Almost half (47%) agree that it was reasonably clear and easy to understand, but over a quarter (29%) disagree » Around a third (34%) agree that the information explained the issues fairly, while more than two fifths (42%) disagree

2.4 Considering the question statements, an absolute majority of respondents agree that: » Hywel Dda Health Board needs to ensure services meet quality and safety standards for patients (87%) » Service planning should treat the ageing population who suffer from long-term chronic conditions as a key priority (82%) » Hywel Dda Health Board should make the best use of scarce resources (82%) » Transport services need to be improved (78%)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

» Hywel Dda Health Board should aim to provide 80% of NHS services locally, through integrated primary, community and social care teams working together (73%)

2.5 Respondent views were divided on the remaining principles, as fewer than half agree and more than two fifths disagree with: » Specialising some services into fewer, fully equipped centres (45% agree; 41% disagree) » Developing specialised services, meaning that some patients will have to travel further for some hospital services, is a reasonable principle (48% agree; 42% disagree)

2.6 Further comments provided revealed that, in general, respondents are most concerned about: » Hospital closures and downgrading (especially with regards to Bronglais Hospital) » Travel time to get to hospital (both as a patient and a visitor) due to closures and downgrading, and whether transport will be improved » How the costs of implementing any changes will be funded and whether it will impact on patients directly

2.7 Respondents also emphasised that: » Women’s and children’s services should be available as locally as possible » There should be less planned care cancellations » Everyone should have access to fully resourced Accident and Emergency departments at their nearest general hospital » There should be more investment in mental health care and treatment

2.8 Respondents who live more than 20km from their nearest general hospital are significantly more likely to agree with the principles overall, while those who currently live within 5km of their nearest general hospital are significantly less likely to agree overall – so those respondents who mainly live in rural areas and already have to travel some distance to their nearest general hospital are broadly more supportive of the current proposals than those that live closer to current services.

Stakeholder Questionnaire

2.9 The stakeholder questionnaire was available online from 11th January to 30th April 2012, and Hywel Dda Health Board (HDdHB) published an online resource centre on their website:

www.hywelddahb.wales.nhs.uk/yourhealth-yourfuture

2.10 This was launched through a press release issued on 21st December 2011. The link to the online resource centre was publicised throughout the listening and engagement period on the HDdHB website and on numerous other websites, as well as being widely promoted through the local press. HDdHB also distributed a DVD information pack to every household, which directed residents to the online resource centre to give their views.

2.11 Paper copies of the questionnaire were available from libraries and GP surgeries across the area, and HDdHB also provided paper copies to residents on request. Completed paper questionnaires were

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

returned directly by post to ORS, and all questionnaires received by 30th April 2012 were included in the analysis.

Questionnaire Responses

2.12 A total of 558 questionnaires were completed online; and 308 paper questionnaires were returned.

2.13 Online questionnaires have to be open and accessible to all while being alert to the possibility of multiple completions (by the same people) distorting the analysis. Therefore, while making it easy to complete the survey online, ORS monitors the IP addresses through which surveys are completed. On this occasion, the monitoring showed that there were 28 IPs which each generated more than one response.

2.14 A total of 58 completed questionnaires were submitted from an IP registered to NHS Wales; however, as a major employer, it is not surprising that many submissions originated from the NHS network. These responses provided a range of different views and ORS therefore consider it appropriate that all of the submissions are individually counted in our analysis.

2.15 The remaining 27 IPs generated a total of 59 completed questionnaires. After careful study of these responses, in which we looked at cookies, date stamps as well as the nature of the answers; none were considered to be identical responses or appeared to be attempting to skew the results, so (given that more than one person at an IP address might want to complete the questionnaire) we have not excluded any online submissions due to malicious intent.

2.16 The paper questionnaires were subject to similar scrutiny, to ensure that the results were not distorted. A total of 48 paper questionnaires were returned that had been pre-printed with “strongly disagree” marked against all question statements. We understand that these questionnaires were produced and distributed by the interest group aBer in a systematic attempt to influence the questionnaire results. To preserve the integrity of the results, ORS has excluded these forms in our general analysis and report of the questionnaire; but the 48 responses provided have been separately considered.

2.17 Therefore, there were a total of 818 valid responses to the stakeholder questionnaire.

Respondent Profile

2.18 Of the 818 valid responses received, a total of 42 responses were representing the views of organisations with 727 being personal responses from individuals (49 respondents did not answer this question). The organisations who provided a response are as follows:

Ambleston Community Council Beulah Community Council Borth Community Council Camrose Community Council Carmarthen Town Council Cenarth Community Council Ceulanamaesmawr Community Council Cilycwm Community Council

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Clunderwen Community Council Cynwyl Elfed Community Council Haverfordwest Town Council Jeffreyston Community Council Llanarthne Community Council Llanddewi Brefi Community Council Llandyfaelog Community Council Llanelli Town Council Llangrannog Community Council Llangwyryfon Community Council Llanycrwys Community Council Narberth Town Council Newchurch and Merthyr Community Council Pencaer Community Council Puncheston Community Council Talley Community Council Tiers Cross Community Council Troed-yr-Aur Community Council Whitland Town Council Ysbyty Ystwyth Community Council A group looking into the effectiveness of Hywel Dda Health Board Bridell Manor Nursing Home Garnant Pharmacy Ltd Keith Davies AM (Llanelli) Nia Griffith MP Pembrokeshire Communities First Shelter Cymru (Information Matters to Rural Communities Volunteer Group, Llanrhian Church) South East Pembrokeshire Community Health Network South Meirionnydd Older Peoples Forum (Save Bronglais Campaign) The committee representing the specialist nurses professional group.

2.19 In reporting the questionnaire results, individual responses and responses from groups have been considered collectively (with any differences identified as appropriate); but in considering the additional open ended responses provided, we have placed greater emphasis on any feedback from organisations.

2.20 The tables on the following pages show the demographic characteristics of individual respondents to the survey.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Figure 1: Age – All individual respondents (Note: Figures may not sum due to rounding)

Age Number of responses Valid % 16-44 111 16% 45-54 108 15% 55-64 219 31% 65-74 184 26% 75 or over 85 12% Not stated 20 - Total 727 100%

Figure 2: Gender – All individual respondents (Note: Figures may not sum due to rounding)

Gender Number of responses Valid % Male 277 39% Female 431 61% Not stated 158 - Total 727 100%

Figure 3: Ethnic Origin – All individual respondents (Note: Figures may not sum due to rounding)

Ethnic origin Number of responses Valid %

White 652 99% Non-white 7 1% Not stated 68 - Total 727 100%

Figure 4: Longstanding Illness/Disability – All individual respondents (Note: Figures may not sum due to rounding)

Longstanding Illness/Disability Number of responses Valid %

Limited a lot 81 12% Limited a little 148 22% Not limited 457 67% Not stated 41 - Total 727 100%

Figure 5: NHS Employee – All individual respondents (Note: Figures may not sum due to rounding)

NHS Employee Number of responses Valid %

NHS Employee 94 14% Not NHS Employee 583 86% Not stated 50 - Total 727 100%

Figure 6: Urban/Rural – All individual respondents that provided a postcode (Note: Figures may not sum due to rounding)

Urban/Rural Number of responses Valid %

Urban 187 31% Rural 415 69% Not known 125 - Total 727 100%

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Figure 7: Responses mapped by area, with shaded zones depicting 5km, 10km, 20km and 50km from named General Hospital – All individual respondents that provided a postcode

Figure 8: Nearest Main District General Hospital – All individual respondents that provided a postcode (Note: Figures may not sum due to rounding)

Nearest Main District General Hospital Number of responses Valid % Bronglais 121 20% Glangwili 94 16% Prince Philip 152 25% Withybush 235 39% Not known 125 - Total 727 100% Figure 9: Distance to Nearest Main District General Hospital – All individual respondents that provided a postcode (Note: Figures may not sum due to rounding)

Distance to Nearest Main District General Hospital Number of responses Valid % Under 5Km 198 33% 5km up to 10Km 100 17% 10km up to 20Km 152 25% 20km up to 50km 151 25% Not known 125 - Total 727 100%

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Listening and Engagement Questionnaire Results

2.21 The following section summarises the questionnaire results.

2.22 Where percentages do not sum to 100, this may be due to computer rounding, the exclusion of “don’t know” categories, or multiple answers. Throughout the volume an asterisk (*) denotes any value less than half of one per cent. In some cases figures of 2% or below have been excluded from graphs.

2.23 Graphics are used extensively in this report to make it as user friendly as possible. The pie charts and other graphics show the proportions (percentages) of residents making relevant responses. Where possible, the colours of the charts have been standardised with a ‘traffic light’ system in which: » Green shades represent positive responses » Beige and purple/blue shades represent neither positive nor negative responses » Red shades represent negative responses » The bolder shades are used to highlight responses at the ‘extremes’, for example, very satisfied or very dissatisfied.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Care Closer to Home

Hywel Dda Health Board should aim to provide most (80%) of NHS services locally, through primary, community and social care teams working together. To what extent do you agree or disagree with this vision?

2.24 Almost three quarters (73%) of respondents agree that Hywel Dda Health Board should aim to provide most NHS services locally (with more than two fifths (46%) saying that they strongly agree), while almost a fifth (18%) disagree with this vision.

Figure 10: To what extent do you agree or disagree with this vision? Base: All Respondents (789)

2.25 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 11: To what extent do you agree or disagree with this vision? Key Themes Care Closer to Home

Key Theme Example comments

Main reasons for agreement with this vision For elderly patients, having care in the community would be better • people prefer to be treated locally Saves on travel cost. Saves patient time. Reduces NHS costs. Reduces • it saves on costs patient uncertainty by being in familiar surrounding/district • it saves time Most people would prefer to have treatment based in their local • it will benefit the elderly in particular community, and at home if possible

Concerns over the current state of community care I agree with the principle of local provision, but experience tells me Some respondents feel that before this vision is put in that local community and social care will have to improve practice, current community care is in need of major considerably to make this feasible in practice improvement Moving care to the community is an improvement, however the target is completely unrealistic and extremely naive. There are no resources to enable the transfer

Current locations and accessibility concerns It is very difficult and expensive for patients and for their relatives to Respondents voiced their concerns about the current visit if they have to travel for hours to get to hospital, and it is often locations in terms of distance and accessibility in impossible to use public transport general, especially for the elderly and people in rural Top quality health care needs to be provided to isolated communities locations as well as larger built up towns and cities Transport is a great problem for elderly non-drivers, and relying on voluntary agencies to get people to clinics etc. is really not satisfactory

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.26 The following chart shows how the responses vary across different sub-groups of the population who stated they agree with the vision for Hywel Dda to aim to provide most of NHS services locally. Results for sub-groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

2.27 Respondents who are aged 75 and over; reside in rural areas; live either between 5km and 10km or between 20km and 50km from their nearest main district general hospital; whose nearest hospital is either Glangwili or Withybush; and those who answered paper copies of the questionnaire are significantly more likely to agree with the vision.

2.28 Respondents who live in urban areas; live less than 5km from their nearest main district general hospital; and those who live closest to either Bronglais or Prince Philip Hospitals are significantly less likely to agree with this vision.

Figure 12: To what extent do you agree or disagree with this vision - Care Closer to Home? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Quality and Safety of Services

Hywel Dda Health Board needs to ensure services meet quality and safety standards for patients. This will mean better patient care.

To what extent do you agree or disagree with this principle?

2.29 The majority of respondents (87%) agree with the principle that Hywel Dda Health Board needs to ensure services meet quality and safety standards for patients, of which more than 7 in 10 (72%) strongly agree. Only around 1 in 10 (9%) disagree with this principle.

Figure 13: To what extent do you agree or disagree with this principle? Base: All Respondents (789)

2.30 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 14: To what extent do you agree or disagree with this principle? Key Themes Quality and Safety of Services

Key Theme Example comments

Staff More time and care should be spent on patients, more staff needed Many respondents feel that quality and safety can be for key areas improved by providing better support for staff; in Ensure staff are trained to provide that care particular: Need to ensure that facilities and staff are available • More time and care should be spent on patients • More staff needed for key areas • Ensure staff are trained to provide that care • Need to ensure that appropriate facilities and staff are available

There is no need to question this principle This should never be questioned. This is a fundamental principle of all Another key theme that emerged with regards to this NHS actions principle is that respondents feel the quality and safety Who is going to disagree with this proposition? of patients should always be paramount.

Equality for rural areas We need some "safe" and "quality" models for a rural population, Respondents are concerned that those living in rural this urban health model will not work areas may be overlooked – namely that the quality and All potential patients should have equal access to a high standard safety standards model will only benefit urban/high and quality of care whether they live in urban or rural areas population areas.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.31 The chart below shows how the responses vary across different sub-groups of the population who stated they agree with the principle that Hywel Dda Health Board needs to ensure services meet quality and safety standards for patients. Results for sub-groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

2.32 Respondents aged 75 and over are significantly more likely to agree with this principle, along with those who live between 20km to 50km away from their nearest district general hospital, and those whose nearest hospital is Glangwili. However, respondents who live under 5km from the nearest district general hospital and respondents whose nearest hospital is Bronglais are significantly less likely to agree.

Figure 15: To what extent do you agree or disagree with this principle - Quality and Safety of Services? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Ageing Population

The ageing population means that increasing numbers of people suffer from long-term chronic conditions.

To what extent do you agree or disagree that service planning should treat this as a key priority?

2.33 More than four fifths of respondents (82%) agree that service planning should treat long-term chronic conditions suffered by the ageing population as a key priority, with half reporting that they strongly agree. Only 7% disagree with this principle.

Figure 16: To what extent do you agree or disagree that service planning should treat this as a key priority? Base: All Respondents (783)

2.34 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 17: To what extent do you agree or disagree that service planning should treat this as a key priority? Key Themes Ageing Population

Key Theme Example comments

All elderly patients deserve to be treated as a key Most older people feel that as they have worked all their lives and priority paid tax and national insurance contributions, they are entitled to Many respondents feel that whether elderly patients this treatment suffer from long-term chronic conditions or not, they Many of the ageing population have probably looked after should be treated as a priority because of factors such themselves over the years and are probably needing care and medical as: treatment due to the natural ageing process  The natural ageing process having a detrimental It needs to remembered that, this is the group of people that have effect on their health contributed the most money to the system that is supposed to look  They have spent years contributing to society and after them therefore deserve to be treated this way

All patients should be treated as key priority All patients should be treated equally Another main theme to emerge is that respondents I strongly agree that whatever our age, a person has the right to the would like not just the elderly with long-term conditions best possible care and to be treated with dignity and respect to be treated as a key priority, but for everyone to be All sections of the community need equal care treated this way, independent of their age. Many also pointed out that it is not just the elderly who suffer Age knows no boundaries when dealing with healthcare. Yes, we from long-term conditions. have an aging population but that doesn't mean the majority of people suffer from long-term chronic conditions I don't believe it is inevitable that an aging population should necessarily lead to people suffering from long-term chronic conditions

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key Theme Example comments

Prevention It should surely be cost effective to invest more effort in helping Whilst some respondents agree with this principle, people to avoid chronic conditions by healthier living e.g. less alcohol many feel that this should only apply to those who have and fatty food a long-term chronic illness providing that it is NOT due Educating the population at a younger age…will reduce the future to self-infliction. In addition, respondents feel that it Hospital burden enormously would be helpful to provide education for future Your priority should be on prevention and keeping people generations to minimise them becoming ill or infirm in independent old age. Truly some charge should be levied on those who need NHS treatment for patently self- inflicted troubles.

2.35 The chart below shows how the responses vary across different sub-groups of the population who stated they agree that service planning should treat this as a key priority. Results for sub-groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

Figure 18: To what extent do you agree or disagree that service planning should treat the Ageing Population as a key priority? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.36 Respondents whose nearest general hospital is either Glangwili or Withybush are significantly more likely to agree with this principle, while younger respondents (aged 16-44) and those whose nearest hospital is Bronglais are significantly less likely to agree.

Specialised Services

Professional advice says that maintaining all services in every hospital is undesirable because it spreads expert resources too thinly, makes it difficult to recruit and retain specialist staff and jeopardises patient safety.

To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres?

2.37 More than two fifths of respondents (45%) agree with specialising some services into fewer, fully equipped centres, while a similar proportion (41%) disagree.

Figure 19: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Base: All Respondents (788)

2.38 The following key themes (specific to this vision) emerged when respondents were to give reasons for their agreement/disagreement if they wished:

Figure 20: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Key Themes

Key Theme Example comments

Concerns over ‘high risk’ groups This will have major transport consequences as an increasingly Respondents showed concern about how the elderly and immobile population need to be accommodated specialisation of services will affect the elderly, children These centres need to be reachable for those with debilitating and those with life threatening illnesses. illnesses and where children can be near their families Some local services may have to be relocated; this particularly causes problems for elderly patients.

Bronglais Hospital Bronglais has not been identified as having anything as a specialist Many respondents feel that Bronglais should be given area which is very upsetting and demoralising specialist services for geographic reasons. Some feel Strengthen the resources of Bronglais; twelve hospitals in the south concerned that this will not happen. and one in mid Wales is not fair distribution Geographically Bronglais should take priority because it serves a large area, and there are already plenty of services within a short distance of the southern area of the Health Board

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.39 The following chart shows how the responses vary across different sub-groups of the population who stated they agree with specialising some services into fewer, fully equipped centres. Results for sub- groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

Figure 21: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

2.40 Respondents who answered the postal version of the questionnaire, along with respondents who live between 20km and 50km away from their nearest general hospital and those whose nearest general hospital is either Glangwili or Withybush are significantly more likely to agree with this principle.

2.41 Respondents who live less than 5km away from their nearest general hospital, as well as respondents whose nearest general hospital is Bronglais or Prince Philip are significantly less likely to agree with this principle.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.42 Figure 22 shows agreement with specialising some services mapped by respondents’ nearest main district general hospital. Respondents whose nearest district general hospitals are Bronglais and Prince Philip show higher levels of disagreement with this principle, while respondents who live nearest to Glangwili and Withybush general Hospitals show higher levels of agreement.

Figure 22: Agreement with specialising some services into fewer, fully equipped centres mapped by nearest main general hospital

2.43 When the results of this question are broken down by distance to their nearest main district general hospital, it can be seen that the closer respondents live to their main general hospital, the higher level the level of disagreement expressed with specialising some services.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Access

Developing specialised services will mean that some patients will need to travel further for some hospital services.

To what extent do you agree or disagree that this is reasonable in principle?

2.44 Just less than half of respondents (48%) agree that developing specialised services which will result in some patients travelling further for some hospital services is a reasonable transformation, while more than two fifths (42%) disagree.

Figure 24: Access: To what extent do you agree or disagree that this is reasonable in principle? Base: All Respondents (795)

2.45 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 25: To what extent do you agree or disagree with specialising some services into fewer, fully equipped centres? Key Themes – Access

Key Theme Example comments

Transport improvements It needs reasonable access. We need improvements in transport Although many respondents agree that this is Agree in principle but again the devil is in the detail. Has anyone reasonable, they raised concerns about the current conducting this review any idea at all as to the nature of transport transport system, which needs improving if patients will connections between the Bronglais catchment area and the be travelling further. Carmarthen/ Swansea hospitals are like? The key is the provision of effective transport systems. The centralisation of services should not be attempted until such a transport system is in place

Consultants should travel Specialised services should be developed in more hospitals with Respondents suggested that consultants could travel to consultants working between hospitals different destinations in order to reduce patient travel But consultants could also travel as part of a network for less time. specialised services The rural nature of HDdHB means that more patients will have to travel long distances. It would be better and contribute less in greenhouse gases if consultants moved between centres

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.46 The following chart shows how the responses vary across different sub-groups of the population who stated they agree that this is a reasonable principle. Results for sub-groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

2.47 Respondents who answered the postal questionnaire, live in rural areas, reside at least 20km from their nearest main district general hospital and who live closest to Glangwili hospital are significantly more likely to agree that the principle for developing specialised services (meaning some people will need to travel further) is reasonable. Alternatively, respondents who are aged between 16 and 44, along with those who live less than 5km away from their nearest district general hospital are significantly less likely to agree.

Figure 26: Access: To what extent do you agree or disagree that this is reasonable in principle? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.48 Figure 27 shows level of agreement that this is a reasonable principle mapped by respondents’ nearest district general hospital; respondents who live closest to Bronglais Hospital show least agreement, while respondents who live closest to Glangwili Hospital show most agreement.

Figure 27: Access: Agreement with this being a reasonable in principle mapped by nearest main district general hospital

2.49 When the results to this question are broken down by distance from their nearest district general hospital, respondents who live nearest (under 5 km) show most disagreement (49%), whereas respondents who live furthest away (at least 20km) show least disagreement (31%).

Figure 28: Access: To what extent do you agree or disagree that this is reasonable in principle? Response by distance to nearest main district general hospital Base: All Respondents (number of respondents in brackets)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Transport

Some patients with certain medical conditions will be eligible for hospital transport for some services.

To what extent do you agree or disagree that transport services need to be improved?

2.50 More than three quarters of respondents (78%) agree that transport services need to be improved, with more than half (55%) reporting that they strongly agree.

Figure 29: To what extent do you agree or disagree that transport services need to be improved? Base: All Respondents (792)

2.51 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 30: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Transport Service Need to be Improved

Key Theme Example comments

Keep care local All patients will be eligible for hospital transport, but this will make Respondents feel that providing more local care would the cost greater than keeping care local be preferable to having to travel further for treatment, It is still better to keep locals in their own hospital which will also help keep costs down and maintain With the expected horrendous oil prices, we should be planning for a patient satisfaction. more local service without patients having to travel

Ambulance Service Current ambulance service is much worse than twenty years ago Respondents showed concern over the current Current overload on the ambulance service must be addressed with ambulance service, and how this will affect patients alternative arrangements for routine patient transport who will need to use it to get to specialised centres. Ambulance services are not good; the air ambulance does not fly at night and relies on voluntary donations

Transport should be available for everyone Hospital transport should always be available for patients when Many respondents feel that all patients should have necessary effective transport services available to them, no I believe transport should be available for all patients if required. A matter what medical conditions they may or may not patient requiring services in Singleton, for example, if living north of have. Carmarthen would have a very long trip, and public transport would probably not be an option

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.52 The following chart shows how the responses vary across different sub-groups of the population who stated they agree that transport services need to be improved. Results for sub-groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

2.53 Those who responded on behalf of an organisation, answered the postal version of the questionnaire, along with those who live between 5km and 10km away from their nearest general hospital and those who live closest to Withybush Hospital are significantly more likely to agree that transport services need to be improved.

Figure 31: To what extent do you agree or disagree that transport services need to be improved? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Making Every Penny Count

The NHS is facing huge funding challenges, so the Health Board must organise services to spend the money it is allocated in a better way, achieve value for money and avoid duplication.

To what extent do you agree or disagree that the Health Board should make the best use of scarce resources?

2.54 More than four fifths (82%) of respondents agree that the Health Board should make the best use of scarce resources, with more than half (56%) saying that they strongly agree. Only 11% disagree.

Figure 32: To what extent do you agree or disagree that the Health Board should make the best use of scarce resources? Base: All Respondents (777)

2.55 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement:

Figure 33: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Making the Best Use of Scarce Resources

Key Theme Example comments

Agreement that money should not be wasted As a member of an organisation who financially supports one of the Hywel Respondents agree that duplication should be Dda hospitals, it makes sense to shop around for best prices as medical avoided and that the Health Board should try get equipment is extremely expensive. Duplication is just a waste of valuable value for money wherever possible. money that could better be spent on other much needed equipment, or even extra staff Cash is extremely short. Money has been frittered and thrown away and it must stop Of course the health board should aim to get value for money. It does not and will not achieve this by duplicating services in the south Wales corridor, while failing to provide essential services in mid-Wales

Managerial and administrative services There seems to be a lot of money wasted on meetings, travel and a lot of Respondents feel that money can be saved by management posts and protection pay cutting managerial and administrative costs, as It has always been, and getting worse, that hospital finance has been top these services are a drain on finances. heavy with administration costs. Not enough has been getting through to the frontline where it should be Reduce managers then there will be more money available

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key Theme Example comments

Protection of patients and services Value for money or the better use of reduced resources is important, but not Respondents want patients and frontline at the expense of patient well-being, comfort or safety services to be unaffected by money saving/cost Yes agree, but cuts should not be made to frontline services cuts, to ensure that patients will be protected Cutting front line services is not the best way of saving money. There must and continue to receive a quality service be a better way

2.56 The chart below shows how the responses vary across different sub-groups of the population who stated they agree that the Health Board should make the best use of scarce resources. Results for sub- groups which are significantly more likely than the overall score are highlighted in green, whilst results which are significantly less likely are highlighted in red.

Figure 34: To what extent do you agree or disagree that the Health Board should make the best use of scarce resources? Demographic sub-group analysis Base: All Respondents (number of respondents shown in brackets). Note: “Limited a lot” and “Limited a little” refer to day-to-day activities limited by a health problem or disability. Distances to hospital are not cumulative – e.g. “Under 10Km” does not include those already counted as being “Under 5Km” so refers to those living “5km to 10km”, etc.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

2.57 Respondents who live in rural areas, live between 20km and 50km away from their nearest district general hospital and those who reside closest to Glangwili and Withybush Hospitals are significantly more likely to agree that Health Board should make the best use of scarce resources. Respondents who live less than 5km away from their nearest district general hospital are significantly less likely to agree.

Information

2.58 Two fifths or more of respondents reported that they have seen/read information about ‘Your Health Your Future’ through a leaflet (46%), the media (41%) and a DVD (40%). This is followed by more than a third who have read/seen the listening and engagement discussion document (39%) and a website or other online resources (36%). Only 1 in 10 (10%) of respondents have NOT seen or read any ‘Your Health Your Future’ information.

Figure 35: A range of information about Your Health Your Future has been made available for the listening and engagement process. Please indicate any information you may have read/seen. Base: All Respondents (784)

2.59 Almost half of respondents who have seen or heard information about ‘Your Health Your Future’ agree that it was reasonably clear and easy to understand (47%), but more than a quarter (29%) disagree.

2.60 A lower proportion feel that the information explained the issues fairly, with only around a third (34%) reporting that they agree with this, while more than two fifths (42%) disagree.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Figure 36: Thinking about 'Your Health Your Future' to what extent do you agree or disagree that it was… Base: All Respondents who have seen or read information about ‘Your Health Your Future’ (number of respondents shown in brackets)

2.61 The following key themes (specific to this vision) emerged when respondents were asked to give reasons for their agreement/disagreement.

Figure 37: To what extent do you agree or disagree that transport services need to be improved? Key Themes – Clarity and Fairness of Information

Key Theme Example comments

Not enough information Firstly the information given is a broad view, not specific to each Many respondents feel that not enough information area. Hence it does not tell the population how the health care is was provided, and also that it is too basic and not going to be delivered in each area specific enough. However, it should be taken into Both the pamphlet and the DVD are professional and slick consideration that some respondents were not aware presentations – well done – but they actually say nothing! that this process is not the full consultation exercise (hence the limited information response stated).

Biased information Some questions appear biased towards responses that appear to Many respondents feel that the information provided support the policies, regardless of the consequences was biased towards Hywel Dda Health Board’s visions I feel this is very biased towards the policies of the Health Board and didn’t think that it was presented in an objective without truly considering the views of patients, especially those from manner. rural settings

Hywel Dda’s public meetings and presentations Some inconsistency between the presentation, the discussion Respondents felt that some of the public meetings document and the displays presented by Hywel Dda HB were confusing and There is a mass of confusion. The information I have received from inconsistent with the background information provided media, leaflets, feedback from line manager, health events and elsewhere. recently presentation all seem to contradict each other

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Further Comments about Service Areas

2.62 Respondents were invited to make any further comments about the service areas mentioned throughout the listening and engagement questionnaire, as well as any general comments. The table below summarises the key themes that emerged from the freetext responses.

Figure 38: Further comments about service areas

Key Theme Example comments

Women’s and Children’s Services As vulnerable members of society they need to be considered high Respondents feel that women’s and children’s services priority. Every effort should be made to move professionals to see should be available as locally as possible in order to them locally, rather than making them travel, for all but specialist reduce travel time both for patients and visitors. input These services need to be as near as possible to home. In most cases women have family and home responsibilities. Children do not benefit from isolation from home and visits. Services should be available locally wherever possible For a sick child it is vitally important that the family is able to visit easily and frequently

Planned Care Reliable planned care, less cancellations would be very welcome Cancellations Planned care shouldn’t take second place to unplanned care. There Respondents want efficient planned care with less must be a dedicated system to moving people up waiting lists (not cancellations, as well as ensuring that any cancelled reducing lists by letting them slip off), cancellation slots should be appointments are filled. used to full effect Planned care is a great idea, providing the appointments are not cancelled at short notice as usual

Planned Care Planned care should be provided in home if possible or at the nearest Locally Based Services facility with the regular staff authority Respondents welcome local planned care and It is important that patients have planned treatment as locally as improvements to local hospitals/services to possible. All hospitals should be improved to be able and continue to accommodate this. provide treatment locally

Unplanned Care All major hospitals should have fully functioning accident & Fully resourced Accident and Emergency departments emergency facilities that are clinician lead and staffed Respondents want easy access to local, fully resourced Aberystwyth needs to have a full trauma team presence in order to Accident and Emergency departments 24/7 (in terms of enable trauma to be dealt with safely and prevent loss of life staff and equipment). Having a local fully-fledged emergency service is critical, particularly in mid-Wales

General Comments From experience, mental health services are lacking in the More investment in mental health community. Huge savings could be made in many areas that would Respondents would like mental health services to be enable us to keep some services improved and to have more money invested in it. At the Adolescent mental health services are underfunded and only provided moment, respondents feel this service is overlooked, a long way from home for the vast majority of people who live in our without enough help being available to those who need region it. Get your act together with the issue of mental health care. I am very concerned about the younger generation. I would be glad to be a volunteer for a support group if you have one in Ammanford Don't think there are enough trained councillors to provide those in mental difficulty with timely support and planned treatment

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Summary information – Significance and Freetext Comments

2.63 The table below shows a summary of the different groups of respondents who are significantly more or less likely to agree with the principles highlighted in the listening and engagement questionnaire.

2.64 Respondents who live further away from their nearest district general hospital (at least 20km away); whose closest general hospital is Glangwili or Withybush, or who live in rural areas are significantly more likely to agree with many of the principles than other groups. On the other hand, respondents who live less than 5km away from their nearest district general hospital, or those whose nearest general hospital is Prince Philip or Bronglais are significantly less likely to agree with many of the principles than other groups.

Figure 39: Do you agree or disagree with...? Demographic sub-group analysis.

Residents significantly Residents significantly Principle MORE likely than average to agree LESS likely than average to agree Aiming to provide most (80%) of NHS Aged 75 or over Lives in an urban area services locally, through primary, Lives in a rural area Lives under 5km from nearest hospital community and social care teams working Completed postal questionnaire Nearest hospital is Bronglais together 5km and 10km from nearest hospital Nearest hospital is Prince Philip 20km and 50km from nearest hospital Nearest hospital is Glangwili Nearest hospital is Withybush

Ensuring services meet quality and safety Aged 75 or over Lives under 5km from nearest hospital standards for patients 20km and 50km from nearest hospital Nearest hospital is Bronglais Nearest hospital is Glangwili

Service planning should treat the ageing Nearest hospital is Glangwili Aged between 16 and 44 population who suffer from long-term Nearest hospital is Withybush Nearest hospital is Bronglais chronic conditions as a key priority

Specialising some services into fewer, Completed postal questionnaire Lives under 5km from nearest hospital fully equipped centres 20km and 50km from nearest hospital Nearest hospital is Bronglais Nearest hospital is Glangwili Nearest hospital is Prince Philip Nearest hospital is Withybush

Developing specialised services which will Lives in a rural area Aged between 16 and 44 mean some patients will need to travel Completed postal questionnaire Lives under 5km from nearest hospital further for some hospital services 20km and 50km from nearest hospital Nearest hospital is Glangwili

Transport services need to be improved Completed the questionnaire on behalf of an organisation Completed postal questionnaire 5km and 10km from nearest hospital Nearest hospital is Withybush

The Health Board should make the best Lives in a rural area Lives under 5km from nearest hospital use of scarce resources 20km and 50km from nearest hospital Nearest hospital is Glangwili Nearest hospital is Withybush

2.65 The following key themes emerged across the questionnaire results in general (i.e. they were commonly mentioned in comments across all or most of the questionnaire) when respondents were asked to give reasons for their agreement/disagreement with the various principles.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Figure 40: Major Themes Throughout Overall Questionnaire Response

Key Theme Example comments

Hospital closures I consider that it is complete and utter madness that a town the size of Llanelli Throughout many of the questions, should lose any of its hospital services numerous respondents voiced their Downgrading Bronglais Hospital is a ridiculous vision concern that hospitals will be closed or I totally disagree with the closure of Llanelli A&E department downgraded due to these principles, especially Bronglais (which respondents It's so obvious that quality & safety of patients is paramount. How can this be feel should be treated specially due to its achieved by downgrading Withybush General hospital? geography) and Prince Philip I do agree with this, however if Bronglais is downgraded and patients are then having to be admitted to hospital in Carmarthen, this will have a detrimental effect on their well being and support network Agree that money needs to be spent wisely, but worrying that this will mean cutting Bronglais' hospital facilities and to expect the sick to travel an unreasonable distance All services must be maintained at Withybush A&E provision in the Llanelli area needs urgent re-consideration I am appalled that you wish to remove A&E departments from some of your hospitals. You will be putting severe strain on the Welsh ambulance service, and Welsh air ambulance

Travel concerns Top quality health care needs to be provided to isolated communities as well as Concerns about travel time are raised, in larger built up towns and cities particular how travelling long distances Transport is a great problem for elderly non-drivers, and relying on voluntary due to closures/downgrades can impact on agencies to get people to clinics etc. is really not satisfactory patients, both in terms of health and cost. Ageing populations with chronic conditions require care as near to home as Particular concern was raised for elderly possible. Your plans to provide emergency and trauma etc. between 60 and 90 and vulnerable patients, as well as those minutes from someone’s home is not acceptable who live in more rural locations Any re-organisation must avoid having the old and sick travelling unnecessarily A fully equipped centre which is not within reach is no use whatsoever This is dependent upon whether the hospital is in an urban area or rural. You require more services in rural settings, due to distance to specialist hospitals Key specialised services have meant a need to travel for many years, but to what extent will specialised services be spread out? An important part of the healing process is receiving visits from loved ones, but if the patient is far away this will put an added stress on both patients and family

Costs On the surface it seems to be a laudable aim but it implies hospital closures and Respondents are concerned about how cost cutting by transferring responsibilities to the “Community”; always a rather improvements to transport, providing care slippery concept locally and specialising services will be Moving care out into the community may be a good thing, BUT what are the funded and also what implications this will additional costs that will be required to be met by council taxpayers rather than have for patients (such as increased travel through NHS budgets? costs) How will it be costed? Helicopters and ambulances are costly both in equipment and man power I agree, but how, when and at what cost? Provision of good district general hospitals with as wide a range of services as possible, whilst accepting a degree of specialisms being based elsewhere, is an acceptable model in this current climate Many people in this area are unable to afford the costs of travel to receive treatment in this area

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3. Deliberative Meetings (i) Focus Groups with members of the public

Introduction

3.1 In order to provide for ‘listening and engagement’ through thoughtful consideration of the issues by a wide range of ‘ordinary’ members of the public, ORS recruited and facilitated seven focus groups across the whole of the HDdHB area during February and March 2012.

3.2 The focus group participants were selected semi-randomly by ORS via random digit dialling in each of the seven locality areas – and broad recruitment quotas were used for area, sex, age and other characteristics in order to ensure a wide cross-section of participants. Groups were held in Welsh as well as English and care was taken to ensure that potential participants were not disqualified or disadvantaged by disabilities or any other factor - and in accordance with standard good practice, the participants were recompensed for their time in taking part. All of the meetings were well attended, and broadly representative in terms of age, gender, social grade, ethnicity and limiting long-term illness.

3.3 Although, like other forms of qualitative consultation, deliberative focus groups cannot be certified as statistically representative, these seven meetings gave a wide range of people the opportunity to discuss the health and organisational issues in detail. We believe the meetings are broadly indicative of how informed members of the public would formulate and express their views in similar contexts.

3.4 Therefore, we believe that the seven meetings are particularly important within the context of the whole listening and engagement programme – because the focus groups were inclusive (encompassing a wide range of people), not self-selecting (randomly recruited), relatively well-informed (following initial presentations of the key issues and policy options), and fairly conducted (through careful facilitation by ORS). There was a considerable contrast between the tone of these thoughtful and considered meetings, on the one hand, and the confrontational atmosphere that HDdHB encountered in some of its public meetings, on the other.

3.5 ORS recruited and facilitated the seven meetings in each of the seven HDdHB localities, as follows: » North Ceredigion (Aberystwyth) – nearest general hospital Bronglais – 12 attended » South Ceredigion (Lampeter) – nearest general hospital Bronglais – 11 attended » North Pembrokeshire (Fishguard) – nearest general hospital Withybush – 13 attended » South Pembrokeshire (Milford Haven) – nearest general hospital Withybush – 13 attended » Amman Gwendraeth (Ammanford) – nearest general hospital Prince Philip – 9 attended » Llanelli – nearest general hospital Prince Philip – 7 attended » Tywi, Teifi and Taff Myrddin (Llandeilo) – nearest general hospital Glangwili – 11 attended

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.6 The aim of the groups was to allow people to express their views about the following broad issues: » The listening and engagement process » Current hospital provision » The guarantees – Maintaining acute hospitals – Principles » Possible Accident and Emergency options; and » Care closer to home.

3.7 Throughout most of the meetings, the main contributions were noted in real-time on screen in PowerPoint so that all participants could see that their views were being recorded properly. In addition, HDdHB staff attended some meetings to listen to people’s views.

3.8 This section of the report presents the main themes and key points arising from the seven focus groups. The opinions expressed were not always unanimous, but we have endeavoured to reflect the range of views expressed. Some important common themes emerged from the group discussions and these are reported below; but where issues related to a particular locality, these have been highlighted. Many quotations have been used, not because we wish to endorse any views, but in order to illustrate some of the more common and important themes and issues.

Summary of Key Findings

3.9 In summary, the main points to emerge across the seven focus groups were that: » Many participants felt that financial management, staffing, standards and bureaucracy needed to be addressed to ensure quality health care provision » The main concerns about the possible concentration of some medical services are about travelling times (due to distances and poor roads) – particularly for older people and their relatives » Despite worries about travelling distances and times, many participants readily accepted that centres of excellence could deliver greater expertise and resilience for serious conditions: so specialisation in centres of excellence was generally welcomed and it was felt that they could help staff recruitment and retention in future » Nonetheless, a tension was evident between the belief that centres of excellence could provide better services and a reluctance to see local hospitals “run down” (an emotional but commonly used phrase) » Providing support for patients and family visitors who need to travel to services was considered a priority » People also wanted diagnostics and follow-up care to be as local as possible » There were divisions of opinion about whether advances in modern technology would allow some care to be delivered more effectively in patients’ homes – some were optimistic and others pessimistic

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

» There was considerable support for more community-based care in principle, but this was balanced by fears that community based services are not yet ready to perform effectively and that money is not available to develop them » People wanted to see better co-ordination and delivery of after-care and post-discharge convalescence; in particular there were concerns about the lack of a ‘joined-up approach’ between the GP and hospitals » There were widespread concerns about poor access to GP services both in- and out-of- hours – reinforcing the idea that there is a pressing need to get effective primary care systems in place before hospitals deliver services differently » Some people clearly felt that poor GP access and services create higher demand for Accident and Emergency services.

Listening and Engagement Process

3.10 Generally speaking, participants across the groups were not particularly aware of the listening and engagement process and the sense of anxiety and concern it had generated in some areas. While some participants remembered receiving the HDdHB DVD and supporting information, they said they had taken little notice of it – for example:

There was something that came through the post, but I didn’t do anything about it (Lampeter resident)

3.11 Where participants were more aware, it was through the reports in their local press and on TV. Indeed, it would be fair to say that, overall, participant’s views had been informed by the media rather than HDdHB directly:

In our local paper they were saying about downgrading Prince Philip Hospital (Ammanford resident)

It has been on the TV (Llandeilo resident)

Press and word from the voluntary sector groups (Llanelli resident)

They said the Accident and Emergency would be closing at five o’clock – that’s ridiculous! (Ammanford resident)

I have got a few press cuttings with me…people are a little concerned around here (Milford Haven resident).

3.12 Of all the groups, participants in Aberystwyth and Llanelli were most aware of the listening and engagement process.

3.13 Aberystwyth participants complained that the Drop-in Sessions conducted by HDdHB had been poorly organised:

The drop-in session in Morlan was on a weekday and unsuitable for working people and those with children

Many people need day-long meetings.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.14 When asked for their overall views on the listening and engagement process, participants were often sceptical:

I don’t think they take a blind bit of notice of what people say (Ammanford resident)

It’s already been decided before they ask us in consultation (Lampeter resident)

I don’t think they’re listening – it seems cut and dried (Llanelli resident)

People are angry – and HDdHB seems unable to get over any positive messages (Llanelli resident).

Views on Current Service Provision

Introduction

3.15 Prior to being presented with the issues currently facing HDdHB, participants were asked for their impressions of current health services, including hospitals and emergency services. Several themes emerged across the localities that demonstrate the Health Board’s predicament. While there was a tendency to focus on hospitals and general policy issues, a number of groups raised particular concerns about their poor experiences of getting access to primary care with GPs.

Health Service Management

3.16 Participants in Ammanford and Lampeter were critical of current financial and management arrangements and felt that ‘waste’ needs to be addressed, particularly in staffing structures:

I think money is spent in the wrong areas – it’s the way they allocate resources. They’d rather employee a clerical manager than a consultant. I watched a TV programme the other day and a doctor had to pay a few thousand for a drill bit – used once then thrown away. He was going to Ukraine for two months of the year and he was buying them. How many thousands of pounds are wasted in equipment being thrown away after one use? (Ammanford resident)

Is it really about patients or saving money? They could save money by sacking all those managers and not wasting money on a new car park at Bronglais (Lampeter resident)

Go back 30 years – look at the way they are run – totally different! They’ve got more money and resources today but yet you were better looked after and treated. They spent time with you (Ammanford resident)

Look at the amount of money we spend here compared to other countries and their service is better than ours. It’s not how much money; it’s what they do with it (Ammanford resident).

3.17 Nonetheless, most residents were not discontented with their health services in general.

3.18 However, it was evident that many did not always understand the nature of those services. For example, the Llanelli focus group was clearly surprised to learn of the more limited nature of what they had supposed was a full ‘Accident and Emergency’ service at Prince Philip Hospital. Many others supposed that their local general hospital necessarily provides the whole range of medial specialisms on a sustainable basis.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.19 Across the whole of the HDdHB there were few who recognised that, for various reasons, some hospital services can be less ‘resilient’ (in terms of staffing, expertise and resources) than others. In the same way, the idea that some hospitals might be advised or have to specialise in some (rather than all) aspects of medical care was unfamiliar to most people.

3.20 Nonetheless, when some of the issues about expertise and resources were explored in the discussions, many members of the groups recognised their significance and were receptive to the idea of ‘centres of excellence’ – and in Llandeilo there was explicit endorsement of the idea of “Intermediate Hospitals” – that offer diagnosis and after-care for many conditions while specialised surgery is provided from larger and more specialised bases. These themes also emerged when ‘staffing’ was discussed.

Staffing

3.21 When asked, participants in each of the localities could recognise that recruitment and training issues might have led to staffing difficulties across Hywel Dda:

Bronglais is currently full of students, trainees and foreign doctors and nurses, it’s chronically understaffed (Lampeter resident)

We need to promote volunteering and create routes into jobs for local people. We need more emphasis on practical skills and less on qualifications for basic care and nursing (Lampeter resident)

There is not enough staff – there is a lot of overseas staff (Llandeilo resident).

3.22 When they became aware of the issues, the lack of specialist staff was of particular concern to participants:

There seems to be only one Orthopaedic surgeon in Withybush (Aberystwyth resident)

They often have the facilities locally but not the staff or the expertise to use them - think about the MRI scanner in Withybush - I think they’re only now trained to use it (Fishguard resident)

I consulted 80 elderly people before the meeting and found that many people are being treated at other hospitals than Bronglais because we don’t seem to have enough specialist services here. It seems OK for us to move, but not for them. If it is hard to recruit consultants, then they should offer incentive salaries, but they don’t seem to recruit efficiently or in a timely way. (Aberystwyth resident)

The general surgeons are not easily replaced due to the increasing specialisation. it is harder to create a network of surgeons of the right standard in each base and with the right supporting services (Aberystwyth resident).

In Aberystwyth participants were keen to stress that this problem could be addressed by a stronger recruitment drive, mobile specialists and training initiatives:

Some positions are not being advertised promptly, probably as a cost cutting measure

Cannot the surgeons travel? We need a helicopter network to move the surgeons

We should train more surgeons within the health board area.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Standards

3.23 Generally, though, when questions are raised about medical ‘standards’ most participants relate the question to cleanliness and hygiene issues, and length of waiting lists, rather than to clinical expertise (probably because they take the latter so much on trust). For example, some participants in Ammanford and Milford Haven criticised standards of cleanliness and hygiene, arguing that they are in decline:

I am scared about BSE and MRSA (Ammanford resident)

My mother was a nurse in the 50s and 60s. They were on their hands and knees. You could eat the food from the floor. Today you wouldn’t want to eat food in some of the hospitals let alone eat it off the floor. (Ammanford resident)

I’ve been appalled by the standard of care for the elderly, some of the staff just drop the food down on the tray and they can’t even feed themselves. This doesn’t happen everywhere though thankfully. They need more staff - especially at weekends (Milford Haven resident).

HDdHB’s Guarantees and Aims

3.24 Participants were presented with the following guarantees – that HDdHB will:

Maintain four acute hospitals Aim to achieve… » Bronglais (Aberystwyth) » Safe services that meet » Glangwili (Carmarthen) guidelines » Prince Philip (Llanelli) » Improved outcomes for patients » Withybush (Haverfordwest) » Value for Money

Distance (particularly in relation to Accident and Emergency Services)

3.25 Even when presented with these guarantees, participants in all seven localities expressed concern that closing any Accident and Emergency services and developing centres of excellence would increase travelling distances to such facilities. Given the isolation and rural nature and remoteness of many areas it was argued that, particularly for the elderly, families and trauma patients, this would have an effect on the care they receive. This was a recurrent theme – for example:

They need to take into account the rurality of the area and the difficulties for elderly people to get around (Lampeter Resident)

Ambulance times are also and issue but I suppose that’s outside the remit of Hywel Dda trust? (Lampeter Resident)

We have a large and diverse population so we need an Accident and Emergency with the core back up services (Aberystwyth Resident)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

We need to be able to get to Bronglais quickly for an effective initial care and assessment (Aberystwyth Resident)

For such a big geographical area with a population which swells in the summer, front-line services need to be protected. My fear is that any changes will just move these further away (Milford Haven Resident)

The moving of patients is a big issue in the light of the travel times and distances – it is geography, geography, geography (Aberystwyth Resident)

Accessibility is important for safety – it is not an alternative (Aberystwyth Resident)

Travel times are difficult (Llandeilo Resident)

Carmarthen is a long way by the motorway (Llanelli Resident).

3.26 However, participants in Lampeter favoured locally-based Urgent Care Centres for less serious cases. They discussed not only the current problem they have accessing Accident and Emergency services in terms of the distance travelled, but also the effect of non-serious cases on waiting times – and a range of views were expressed about this:

They should charge drunks around £20 for using the Accident and Emergency for clogging it up!

Local drop-in centres would take the strain off Bronglais and Glangwili and would be closer for us. Glangwili is 45 minutes and Bronglais is an hour at the least.

3.27 Participants in some of the groups suggested that they would be less concerned if there were adequate medical transport services in place, in particular air ambulances:

The Police force has got three helicopters and there’s only one air ambulance. I’d rather see my money supplying an air ambulance (Ammanford resident)

We need a publicly funded 24/7 helicopter if services are going to be centralised (Aberystwyth resident).

3.28 Participants in Llanelli and Ammanford were especially concerned with the status of Prince Philip Hospital and asked why, considering the size of the area’s population, the closure of its Accident and Emergency Unit is being considered as an option:

With the largest population we need most of the services (Llanelli resident)

Carmarthen is a long way by the motorway (Llanelli resident)

If you go with the population it’s the wrong way round. It doesn’t suit population needs, it just doesn’t make sense (Ammanford resident)

Prince Philip has got the largest catchment area (Ammanford resident)!

3.29 Of course, in this context, it is significant that these groups were almost wholly unaware of the actual nature of the ‘Accident and Emergency’ service at Prince Philip. In other words, there is the paradox that some people are (understandably) concerned to protect services that they do not actually have. This makes it very hard in general for the public to appreciate the full significance of any proposed

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

changes – for example in relation to possible Urgent Care Centres. In the focus groups it was possible to clarify the nature of Prince Philip’s ‘Accident and Emergency’ service, but in the wider public forum this is less easy to do.

3.30 Participants in Aberystwyth were concerned that Bronglais has already suffered the loss of some services and they felt strongly that its strategic location needs to be taken into account when considering future provision:

We get the impression that the hospital is gradually being downgraded

People come to Bronglais from a big area surrounding – and we need to be able to cater for Tywyn people, for instance

Bronglais is actually not on the edge but in the centre of a much wider area.

3.31 Participants in Milford Haven were worried that, after recent investment in the Accident and Emergency service at Withybush, the service might close:

They spent millions upgrading A&E in case the terminal blows up (Milford Haven Resident).

3.32 While concern was expressed about the closure of Accident and Emergency services, participants in most of the localities expressed dissatisfaction with service they currently receive at their local Accident and Emergency unit.

3.33 Participants at Fishguard felt the Accident and Emergency Unit at Withybush is limited, with many people being turned away or told to go to Glangwili for fairly minor acute injuries such as broken jaws, cuts, or stitching for wounds:

Is Withybush really an acute hospital or has it already been downgraded? (Fishguard resident)

Keep Withybush as a general hospital. They upgraded the Accident and Emergency but it can’t cope with the population it serves now and has to send most people to Glangwili (Fishguard resident)

They only run a limited Accident and Emergency (Fishguard resident).

3.34 Participants in Llandeilo were generally positive about the service received at Glangwili, but complained about long waiting times:

The new Accident and Emergency at Glangwili is very good – but it seems busy and you have to wait at times

My son sat in Accident and Emergency for four hours with a broken arm.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.35 Participants in Ammanford and Llanelli also criticised the Accident and Emergency Services available locally:

The Accident and Emergency service is poor at diagnosis (Llanelli resident)

Glangwili is awful to visit and people have to walk home (Llanelli resident)

I have such little confidence in Llanelli Hospital. It’s a shame because it’s not very old but so many services have been taken from there to Glangwili (Ammanford resident)

3.36 Participants in Ammanford argued that, under certain circumstances, they would prefer to use the Accident and Emergency service at Morriston. They also argued that, depending where they were, it would be a shorter journey:

I’ve got a colleague who was suffering from high blood pressure – he was told if he had a heart attack to go to Moriston because there aren’t any specialists in Llanelli

I took my son down to Llanelli about four years ago – he’d split his finger like a banana skin. The consultant wanted to stitch him up there and then until his supervisor came along and told him to send him to Carmarthen. We went to Carmarthen and they rung Morriston and Morriston said to send him down there

I’d go there if something serious. I think Morriston has got a good name – Llanelli hasn’t!

There are one lane roads not two lane roads here. You can’t get around the roads here at 70 miles an hour!

3.37 On the other hand, some residents in Llanelli believed they were not allowed to go to Morriston Accident and Emergency because they would not be treated there.

3.38 Some participants in the Aberystwyth group had positive experiences of the service provided at the Bronglais Accident and Emergency unit:

We have competent medical teams at A&E who can treat us and/or send us on to specialist centres – for example for spinal injuries

We do have an efficient triage system

We have a good A&E that stabilises or treats us, but for serious cases we have to be moved to more specialist centres.

3.39 The group also felt that while an Accident and Emergency was required for stabilisation, they would be happy to be sent to more specialist centres subsequently:

We have a large and diverse population so we need an A&E with the core back up services.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Specialisation and Centres of Excellence

3.40 Participants were asked to consider the case that specialist doctors and teams working in properly resourced centres of excellence save more lives than less resilient services. Specialisation and centres of excellence were generally welcomed across the localities – as illustrated in particular by the following wide range of medical examples:

We don’t mind special centres for really serious illnesses – maybe we should travel more to specialist centres? (Llandeilo resident)

Premature births (pre-36 weeks) have to be referred to Singleton and that seems reasonable providing there is capacity there. Withybush and Carmarthen can deal with 36 week babies and it would be nice if Bronglais could too… (Aberystwyth resident)

It is great to have specialist centres for conditions that are on-going (Ammanford resident)

The general surgeons are not easily replaced due to the increasing specialisation – it is harder to create a network of surgeons of the right standard in each base – and with the right supporting services (Aberystwyth resident)

For a spinal operation, we have to go to Withybush – but we should not have to go there for the pre-operational assessments two weeks before (Aberystwyth resident)

I’m happy to go to Morriston for a pace-maker, but I want to be able to get treatment for a heart attack more locally (Aberystwyth resident)

If there is a very premature baby a high level of support is needed – and it has to be reasonable in the light of the level of demand/need per year – it has to be reasonable to refer cases to specialist centres (Aberystwyth resident)

I would go to Prince Philip for the best breast cancer care (Aberystwyth resident)

For a possible melanoma my GP did a biopsy in the surgery and the test came back positive – so I was referred to Singleton where a day case operation removed quite a large deep growth – so was this a really simple case that could have been done here or not? He gave me several options for treatment and I was able to decide. Afterwards he said I could go to Carmarthen in future (Aberystwyth resident)

Prince Philip has an excellent breast cancer centre – and no one would mind going there for dedicated treatment (Llandeilo resident)

We don’t mind special centres for really serious illnesses – maybe we should travel more to specialist centres? (Llandeilo resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.41 Some participants thought that the creation of centres of excellence could encourage staff recruitment and retention in future – and some had optimistic assessments of what might be possible:

Pembrokeshire is lovely place, surely if you created a specialist centre in Withybush, then people would come to live and work here. You have to make it attractive to them and then they’ll come and stay (Milford Haven resident)

Specialist centres will eventually be able to recruit and train staff to go back into the general hospitals so we should all benefit in the long term from the plan (Fishguard resident).

3.42 The example of breast cancer care in Prince Philip was cited by participants of an example where specialism is working well:

The breast cancer unit is excellent – it has a really good reputation (Llanelli resident)

I would go to Prince Philip for the best breast cancer care (Aberystwyth resident)

I think the specialist centre for breast cancer in Prince Philip is excellent and is a great example of the benefits of having a well-organised service. If you want these specialist centres then you have a good example there, but you must fund them adequately or they won’t work. Prince Philip is very efficient and things are done quickly (Lampeter resident).

3.43 Despite the general optimism, however, travelling distances and the associated costs concerned participants across the localities:

It would be difficult to travel miles for dialysis (Llandeilo resident)

In the north of Hywel Dda some patients would have to travel to England for some services e.g. orthopaedic surgery (Llandeilo resident)

Travel times are difficult (Llandeilo resident)

Accessibility is important for safety – it is not an alternative (Aberystwyth resident)

The moving of patients is a big issue in the light of the travel times and distances – it is geography, geography, geography (Aberystwyth resident)

Travelling long distances for specialist aftercare is unhelpful for families and patients and is hugely expensive for patients too (Lampeter resident)

A 35-40 minute trip from Fishguard to Withybush is already long if it’s an emergency, you haven’t got a car or you’re waiting for an ambulance. This will become 2-3 hours one way if services go to Carmarthen or Swansea or Llanelli! (Fishguard resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.44 However, in two of the groups (Ammanford and Milford Haven) distance to travel was more of a concern for older participants, whereas younger participants placed more emphasis on receiving the best possible care:

I feel that if, say, Cardiff had the best care for me at the time, I’d go there and I’d be eternally grateful. I know it would be hard for family and friends to visit but I’d trade that for the best possible care. I see other people’s point of view but I think quality of care would come first (Younger Milford Haven resident)

I’d travel to Cardiff to get the care I need. I’d go wherever to get best care (Younger Ammanford resident)

The cost and time it takes to go for an appointment is an issue for us here. It takes all day in a taxi to go to hospital and back even for routine checks because you’re picking up other people along the way and on the way back. (Older Milford Haven resident).

3.45 The elderly and people with a chronic condition were considered to be the hardest hit by travelling longer distances to access specialist care. It was argued that thought should be given to retaining the specialist services that are accessed by these groups:

Nearly half of the residents here are over 50, so we have to plan for the needs of the ageing population. Orthopaedic and palliative care are just some of the things that need to be retained locally (Fishguard resident)

There are a lot of conditions where people can’t afford the exhaustion of travelling away (Ammanford resident)

Access should be reasonable – you shouldn’t have to travel long distance, especially if you’ve got a long-term chronic illness, you shouldn’t have to travel to London! (Ammanford resident).

3.46 Overall, providing support for those who need to travel was considered a priority – as was providing diagnostics and follow-up care as locally as possible:

For a spinal operation, we have to go to Withybush – but we should not have to go there for the pre-operational assessments two weeks before (Aberystwyth resident)

It is important to do the pre- and post-op care locally so people can then go to the specialist hospital on the day (Aberystwyth resident)

Whatever can be done locally should be done in terms of pre- and post-op follow up (Aberystwyth resident)

We need GPs to be able to do more screening and tests and biopsies…(Aberystwyth resident)

We might need to support those who have to travel (Llandeilo resident)

We don’t want to have to keep travelling widely for all the diagnostic tests that might be needed (Llanelli resident)

I had no problems with Morriston as a specialist centre to remove my kidney, but I had the tests done in Prince Philip (Llanelli resident)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

I understand that different hospitals might have to deal with different cancers, but the general hospitals should be able to do the biopsies and follow-up care (Llanelli resident)

I think it would be good to have the preliminary test at a local centre and then a specialist operation at a centre of excellence. The aftercare can then be given close to work - that works for me (Lampeter resident)

You want the best possible care and you don’t mind travelling for specialist care but you do want your assessment and aftercare to be as local as possible (Lampeter resident).

3.47 Participants across the localities felt that advances in modern technology could allow some specialist care to be treated more effectively in patients’ homes:

If my wife needs dialysis we were going to look into having a machine at home rather than having to travel to Morriston or Carmarthen. In today’s age, travelling shouldn’t be an issue when it could be at home or at a local hospital. It is supposed to be the 21st century…we have gone backwards! (Ammanford resident).

3.48 But some were sceptical about how practical this would be:

For tele-health and distance diagnosis to work you need to get your patient records and IT systems together to make it work. The systems and the technology in such a big NHS machine aren’t there at the moment (Lampeter resident).

3.49 Some participants in Lampeter also argued that specialisation is an urban solution to a rural problem:

The numbers needed for a specialist centre don’t add up because we don’t have a big enough population to make it viable. You’d need around 300,000 as a base- that’s what they’re working with in England

It’s not centralising anything, it’s taking it away from the local areas

You can’t have specialist in every hospital - it’s just not feasible! Isn’t a comprise position to get specialists to come to other hospitals on a regular basis?

3.50 Some participants cited core services that they felt should be retained in their local general hospital:

We do a lot of knee operations in Llanelli – it is good to keep orthopaedic surgery here (Llanelli resident)

Acute medicine, acute general surgery (appendix), obstetrics/maternity (not premature and not Consultant-led), Accident and Emergency – and we would need radiology and specialist diagnostics support units (Llandeilo residents)

Apart from open heart surgery and neurology, all general hospitals should be able to deal with general abdominal surgery (Llanelli resident)

If we had a slightly improved Urgent Care Centre and had general surgery here, then that would go a long way to guaranteeing the status of the hospital – and the breast cancer specialism and geriatric services are excellent bonuses (Llanelli).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.51 Overall, there was a tension between people’s recognition that specialist centres are excellent but that they want local services – as illustrated in this not quotation from Llanelli, which reflects the widespread concerns about ‘downgrading’:

People agree with centres of excellence for the infrequent illnesses – but we worry about the “cottage hospital approach”!

3.52 The challenge seems to be for HDdHB to explain the principle of what in Llandeilo were referred to positively as “intermediate hospitals” (in relation to selected services) without appearing to devalue particular sites altogether.

Care Closer to Home

3.53 In general, participants welcomed the idea of more community-based care – although again there was scepticism about how it will work ‘on the front-line’:

The population is getting older and they need to have services nearby - I welcome this idea if it works (Milford Haven resident)

Think of the money that’s wasted sending people for a test by ambulance and taxi. I go to Swansea every month for blood tests – why can’t I have these locally? Travelling is a killer – especially when I was on dialysis in Swansea! (Fishguard resident)

I think it would be great to have more minor treatment and routine things done by your GP or at a local health centre but, if this is about saving money, how can it work! I’ll wait to see some proposals before I agree to it - I hope they prove me wrong and I’ll keep an open mind (Milford Haven resident)

That seems okay if it is well-co-ordinated and if people really do get the care they need – and it will cost money (Llandeilo resident).

3.54 But poor co-ordination of services was considered a real barrier:

Social care and health still seem very separated and there is a lot of politics about the respective budgets…There would be lots of different elements to co-ordinate (Llandeilo resident)

Elderly people want to avoid ending up in hospital, but it can be very hard to get effective care – and people are frightened of being vulnerable (Llandeilo resident)

My local authority used to care for learning disabilities and mental health and there were lots of disagreements about who would pay – the tension in health and social care comes out in relation to what social care visitors can do in terms of medicating patients – they are not allowed to assist unless drugs are provided in special containers (in Carmarthenshire) (Llandeilo resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.55 Some participants also questioned the resources that would be made available for this:

If care centres can be developed and adequately funded, for example like a super GP service, but I need to be convinced that the money is there and that this is not just a cost-cutting exercise (Fishguard resident)

Care in the community can be very expensive – if you are trying to give real quality of life (Llandeilo resident)

If the agenda is cost-cutting then care in the community is not the best route (Llandeilo resident).

3.56 The Aberystwyth group argued that more cancer care could be provided locally:

We need GPs to be able to do more screening and tests and biopsies

Radiotherapy is done at Singleton – it seems a long way to travel for a short treatment

We need more chemo care to be done locally…could there be a mobile radiotherapy unit?

3.57 It was generally agreed that community-based care, after-care and post-discharge convalescence is in decline and needs improving - with many adding that traditional ways of working should be reinstated:

Revert to the old community hospital model for midwifery and births! Like it used to be (Lampeter resident)

The community hospital in Pembroke Dock is very modern and clean. It’s just been refurbished… but Tenby hospital is very old and in need of updating and investment (Milford Haven resident)

In the old days hospitals used to have Almoners who would see patients before discharge with the doctors – but now the discharge liaison is done through another department. It can all seem a bit disjointed (Llandeilo resident)

The old fashioned Home Helps used to be excellent, but the whole ethos has changed with risk assessment and professionalism so care has diminished (Llandeilo resident).

3.58 It was argued that communication and clinical pathways are poor at the moment. A ‘joined-up approach’ between GPs and hospitals was seen as a vital component in developing community-based integrated care:

I’m not sure even GPs know what they’re doing or where to send people at the moment (Lampeter resident)

There would be lots of different elements to co-ordinate (Llandeilo resident)

It’s access to medical records. You go from one hospital to another and they can’t access your medical records (Ammanford resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.59 There were concerns about the management of discharges from hospital and the co-ordination of aftercare:

My husband was discharged prematurely after surgery when he still had an infection – and it was hard for him to get back into hospital (Aberystwyth resident)

Discharges must not be premature – and surgeons should take notice of patient symptoms of pain (Aberystwyth resident)

My son got little advice when he was discharged from Bronglais with a broken leg – and phoning the ward after he’d left was difficult – no one seemed to want to give advice (Aberystwyth resident).

GP and Out of Hours Services

3.60 There were complaints in each of the localities about poor access to GP services – both in and out of hours – and this issue undoubtedly had a big influence on people’s assessments of the feasibility of the ‘care closer to home’ agenda. In particular, while participants supported more community-based care in principle, they were concerned that in practice there is a pressing need to get effective primary care systems in place before hospitals begin to deliver services differently.

3.61 The concerns about GP access were widespread:

I have written to complain about the poor GP access and I did not even get a reply. I am an asthmatic and need access to the GP (Llanelli resident)

I rang today (Thursday) and all appointments had gone for three weeks so they asked me to phone again tomorrow morning (Llanelli resident)

The GPs redirect a lot of patients on to pharmacists for advice and treatment (Llanelli resident).

3.62 In Llandeilo people were fairly positive generally about their GPs (We are fairly lucky here)– but there were still important complaints about access – for example:

The GP is not the problem, it is the receptionist! They are a barrier!

If you’ll see any GP it is fairly quick – but you often need continuity

The appointments systems are very poorly run – it is hard to produce a fair system – and there is a lot of pressure.

3.63 There was recognition that GPs can use a range of service options flexibly:

They use nurse practitioners very well – it reduces the pressure (Llandeilo resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

3.64 There was also an understanding that GPs can specialise and that this is beneficial to patients providing they can access the right doctor:

Some GPs have special interests – and it would be good if this was publicised more – so that you could go to a dermatologist if necessary (Llandeilo resident)

It’s a good idea to have more specialist doctors for nutrition and so on (Llandeilo resident).

3.65 Out of hours services were considered to be particularly poor and in need of considerable improvement:

I phoned the local out of hours services for an infected splinter in the finger and then waited two hours for a phone call back which then told me to go to A&E! It was only a minor injury but the out of hours surgery at Bronglais would not deal with it so the phone call sent me to Accident and Emergency (Aberystwyth resident)

The three GP surgeries should combine to offer a more effective out of hours service – we need to improve GP services (Aberystwyth resident)

But the GP contracts allow them to opt out of weekend provision so a merger would do little good! (Aberystwyth resident)

3.66 In some localities it was claimed that poor GP out of hours services creates a higher demand for Accident and Emergency:

A&E is open all the time but the primary care services are not and the out of hours service is poor – so people go to Accident and Emergency (Aberystwyth resident)

GPs seem overwhelmed – appointments are very difficult to get in some cases. That’s why Casualty is inundated! (Llanelli resident).

3.67 There were concerns that GP services contribute in other ways to patients having to go to hospital and travel unnecessarily:

We need GPs to be able to do more screening and tests and biopsies (Aberystwyth resident).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4. Deliberative Meetings (ii) Focus Groups with Members of Staff

Overall Summary

4.1 Whereas most of the submissions from the public and stakeholders during the listening and engagement process were overwhelmingly concerned with “keeping the local DGHs” – on the basis of distance, travel times and ease of access for patients and their families, we have seen that the randomly selected members of the public in focus group discussions were much more tolerant of HDdHB’s direction of travel based upon their interest in issues like recruitment, critical mass and resilience, excellent care, and the potential for more care in the community.

4.2 In terms of locating the HDdHB staff we spoke to on the opinion scale (from outright opposition to relative support), most of them – particularly the senior staff – were relatively understanding of the Board’s direction of travel, though there were major variations, and both junior and senior staff at Bronglais were highly critical of the Board’s current thinking.

4.3 Indeed, across Hywel Dda senior staff generally agreed with HDdHB’s key aims in relation to the main scenarios outlined. In one meeting the core challenge facing HDdHB was stated:

Our area is so rural and large that we have four hospitals – but for our catchment population we strictly need only one, which could then provide all the services. But now trying to ‘spread’ everything thinly causes duplication, poor services and under-use of expensive equipment. (Prince Philip)

4.4 Across most of the staff groups there was very little opposition to HDdHB’s main assumptions and principles; indeed in the more senior groups there was considerable support for the need to consider the location of hospital services carefully.

4.5 Obviously, though, there were different views on the location of particular services in the light of HDdHB’s principles. In some cases people need to appreciate that if they will, the ends then they should also will the means.

4.6 However, there were some clear conclusions: for example, that breast cancer surgery should continue to be at Prince Philip, which was universally recognised as a centre of excellence. In contrast, most senior staff were very open-minded about where colorectal cancer should be based, but they felt the decision should be taken on the basis of facts and facilities, not emotional issues or special pleading.

4.7 The most opposition to HDdHB’s strategic approach was found at Bronglais, where both junior and more senior staff criticised the Board’s strategy as reducing services in the north in favour of those in the south. The junior staff said there were even fears that the hospital might be closed and the senior staff were concerned about services ‘running down’.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.8 Across Hywel Dda, the more junior staff tended to focus on and favour their own hospitals in considering the overall allocation of resources. One factor influencing the more junior staff in some groups was their unfamiliarity with, and dislike of, data about comparative mortality rates drawn from “The Best Configuration of Hospital Services for Wales: a Review of the Evidence”. The more junior staff were unfamiliar with any such data (at both the national and Health Board levels) and in many cases they rejected it as inherently ‘untrustworthy’ or irrelevant to the position of their hospitals. Given that the Health Board needs to encourage staff to be receptive to change based upon an assessment of the current and future resilience of services, it is probably important to promote a greater understanding of the relative strengths and weaknesses of different service centres. Of course, it is important not to alarm or demoralise staff and the public with mortality data that they might not fully understand, but it seems there is scope for a more frank review of the differences in patient outcomes and experiences between more and less resilient services – in order to counteract the impression that most clinical services can be delivered everywhere equally.

4.9 The remainder of this chapter reviews the staff discussions in detail, starting with the schedule of groups and the discussion agenda.

Staff Focus Groups and Discussion Agenda

4.10 As an important part of the listening and engagement process, HDdHB sought to involve its staff across each of the four hospitals by commissioning small focus group discussions at three main levels: Staff up to and including Grade 7

Staff at Grade 8 and above

Doctors

4.11 In total, twelve confidential meeting facilitated by ORS were planned and HDdHB conscientiously invited volunteers, but unfortunately the take-up was not as enthusiastic as hoped and some meetings had to be cancelled or had poor attendances (for example, only one doctor attended one of the three planned meetings). Nonetheless, a total of nine meetings took place – as outlined in the schedule below: Place Date Grade Attendance Withybush March 5 Up to 7 6 Glangwili March 12 Up to 7 4 Bronglais March 15 Up to 7 9 Bronglais March 15 8+ 7 Prince Philip March 22 Up to 7 7 Withybush April 23 8+ 8 Prince Philip April 27 8+ 2 Glangwili April 30 Doctors 1 Glangwili April 30 8+ 3

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.12 Owing to the relatively small numbers in some case, it is inappropriate to report each group separately, and in any case there were some important common themes. Therefore, this review seeks to draw out the main themes and comments in order to show the general tenor of opinion.

4.13 In each group, the discussions ranged over the following topics areas, although not all of them could be fully covered in each group in meetings lasting between two and three hours:

Listening and engagement process

Recruitment and retention of medical staff

Case for specialised centres

Care closer to home

Mental health

Women and children

Unplanned care

Planned care, including Acute medical Acute surgery Trauma services Elective theatre services Breast cancer Colorectal cancer.

4.14 In the following report, quotations are given in italics (usually indented). Verbatim quotations are used not because ORS agrees with them, but to illustrate important themes or points of view – but, of course, the comments are not ‘objective fact’ but people’s perceptions.

Current Services

4.15 This section should not be interpreted as a systematic and comprehensive review of current services – for it is really a number of insights provided by staff and based upon their experiences and observations. Focus groups such as these could not adequately cover the complexity of medical services across the hospitals and only some staff took the opportunity to comment on the quality of services provided locally. Many staff were understandably ‘protective’ of their own hospitals, but some recognised that improvements are desirable. For example, junior staff at Withybush referred to surgeons with insufficient case loads and a lack of resilience in vascular services and urology:

I would prefer to have a really experienced surgeon (Withybush)

We have problems regarding vascular services – many come to us when they have nowhere else to go – and the service here is not good; we need to look at vascular services seriously: vascular patients fall through the net at Withybush (Withybush)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

We have a lot of urology problems when elderly people arrive in A&E in retention – but the services for men are very poor – they get catheterised and then returned to their GP – so catheters are left in the patient for too long and we have a very limited service for removing them in hospital. We don’t manage the condition very well or investigate why the retention happened and we have no resident urologist at Withybush – we don’t have enough capacity in HDdHB (Withybush)

We do not treat Pembrokeshire urology and vascular patients as quickly and effectively as those from Carmarthenshire – there is not the capacity in Withybush (Withybush)

4.16 Most staff were not generally critical of services and showed little interest in relative mortality figures; but there was one conspicuous exception at Withybush:

Wales seems like a third world health system. I’m not surprised that mortality rates are higher here and I think they’ll get worse until we get a grip on things!

4.17 There were descriptions of stretched mental health services in Bronglais and Prince Philip:

We have only seven beds on Enlli ward – our services are not fit for purpose without more psychiatrists and unless it is treated more seriously. We get people for surgery and trauma who have dementia – but the ward is so stretched that it cannot help with these cases properly. (Bronglais)

Our hospital crisis team for mentally disturbed patients does not operate over night – it only starts at 8am (Bronglais)

We are short of mental health beds – so people have gone to Aberystwyth instead – it is variable (Prince Philip).

It can take a long time for patients to be assessed by the psychiatrists in A&E – and we do not have mental health trained nurses (Prince Philip)

The medical wards have a lot of dementia patients and it can take up to five weeks for them to be assessed on the ward – so there are delayed discharges and they can also contract infections because they cannot cooperate with their care – and some can be dehydrated and mal- nourished. We have specialist dementia nurses but we never see them on the acute medical wards where they are needed (Prince Philip).

We can improve waiting times in mental health and other services – it sometimes takes four months to see a consultant (Glangwili)

Mental health in Ceredigion is neglected compared with the other centres (Bronglais).

4.18 There were concerns about pressures on elective surgery in Bronglais:

The reduction in beds means we have to cancel many operations because the surgical beds are allocated to emergency cases – we do not have enough beds for elective surgery and emergencies (Bronglais)

Many emergencies arise because we send some patients home too quickly and they return – so elective cases are delayed and become emergencies (Bronglais).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.19 Finally, a number of staff worried about the ambulance services:

The ambulance service is very poor – because there is a lack of paramedics and ambulances – they are not “hospitals on wheels” – they cannot really care properly for patients in transit on these roads. The public is being misled about what they can do – it can take 8/9 hours to get an ambulance for a patient transfer (Bronglais)

The ambulance service is stretched by having to transport patients long distances for emergencies and then back to their home area for more local care afterwards. (Glangwili).

Recruitment Difficulties

4.20 In general, the focus groups recognised that HDdHB has serious senior recruitment difficulties:

Surgical services are a worry – two surgeons are due to retire (Bronglais)

It is hard to recruit mental health nurses – so wards have had to be closed due to shortages of staff – I had 15 applications for a staff nurse and the shortlist is 9 – but they are not local and may not turn up because they will have applied for multiple jobs (Bronglais).

4.21 Some junior staff blamed the current organisational uncertainty as the cause rather than any other factor. Similarly, staff in Bronglais believe this is due to the downgrading and neglect of the hospital by a south-facing management team and were critical of the way the organisation manages the advertisement and the invitation to interview process:

The recruitment and invitation to interview process is very impersonal – there is no personal communication with them whatsoever – they are notified of interview only if they revisit the NHS Jobs website where the jobs are advertised – but HR might then contact them if they do not hear from them (Bronglais)

There is a nationwide shortage of radiographers – but we do not advertise in a way that promotes Ceredigion (Bronglais).

4.22 The fact that Bronglais is not a teaching hospital was also considered a barrier to filling clinical positions.

4.23 At the other extreme, some felt that Wales’ ‘different health system’ is part of the explanation:

The system of health is very different in Wales and there is a big lack of resources without an expectation of any real improvement. London patients would be kicking and screaming if they had such poor services! Wales is putting itself out on a limb and I think that’s why people don’t want to come here at a senior level (Withybush)

Consultant salaries in England are higher than here – they start £2K higher and finish £6K higher – the pay ranges are different (Bronglais).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.24 However, senior staff at Glangwili and Prince Philip argued that the “Welsh factor” does not put people off and recognised that urban areas further east in Wales can attract staff more readily and attributed recruitment difficulties to rurality and the lack of prospects for career development, training and work experience:

Recruitment is an issue because we are not able to have specialist throughput, which is why the surgery expertise goes towards Cardiff. It’s hard to recruit. There are about four or five key vacancies in my areas, whereas at Morriston they are probably somewhere near full establishment (Prince Philip)

Vacancies increase the further west you go and many are long-standing (Prince Philip)

Cardiff can attract more and better staff than West Wales. Recruitment problems are caused by being remote and non-urban, and there are better careers in Cardiff (Glangwili).

This is coming to be seen as an area where people don’t progress – so candidates don’t apply or we get the weaker candidates who can be taken on in desperation (Glangwili)

Cities are always more popular than rural areas with high proportions of elderly people – young staff want to work in the cities and come here as the 3rd or 4th choice – the facilities and work experience is less here than in other areas (Glangwili).

4.25 The difficulties recruiting was said to have led to higher staffing costs through the increased use of locums and pressures to cover staff rotas and sickness:

Once you go below a critical mass, it becomes harder and harder to recruit because people do not want to join because you are going to be on call more frequently – so we end up filling the service with locums and that’s not brilliant (Prince Philip)

Some excellent temporary registrars leave and we get locum registrars instead, who are very expensive (Glangwili)

We have one consultant two days a week and then a staff grade psychiatrist (the 3rd in a year) – but senior cover is an issue if one is off sick (Prince Philip).

4.26 A senior member of staff at Bronglais felt that the problem of geography could be overcome if senior staff are rotated around the hospitals to give them more experience.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Centres of Excellence

4.27 Some senior staff were particularly emphatic in supporting the Board’s thinking in respect of centres of excellence:

We need to make best use of resources. Money is reducing and we have a historic deficit. Recruitment is difficult for senior posts in some professions and some clinical services are unsafe currently. We need to reconfigure services to create more centres of excellence and better quality services. We need to base service options in how many operations are performed at each base – to show the importance of patient numbers and case volumes to the public. And the strategy needs to be seen to take account of nursing input (Glangwili)

We need to tell patients that they are going to the best providers – and they will accept this if it is explained – but so far the options on clinical services have just caused anxiety. (Glangwili)

4.28 If not always so emphatic, overall, senior staff generally very much agreed with HDdHB’s arguments for developing medical specialities in appropriate centres of excellence. For example:

I’d want to be treated wherever’s best for whatever condition I have. Maybe I know more because I work in the hospital, so I know the range of things. If I had breast cancer, I would come here, where the treatment is second to none. If I wanted a scan, I’d come here because we’ve got the first-of-its-type MRI scanner. But I would be dubious coming here if I needed bowel surgery (Prince Philip)

If I was to have a hernia operation then I think I would have that done in Carmarthen. If I had lung cancer, or some unusual cancer, then I think I would go to London if I possibly could because I know my chances of being cured would be enhanced. Even if I went to Swansea for some sort of care my chances of survival would be less than in some specialist centres (Prince Philip)

We want the best care for people – to ensure that for example broken legs are set correctly (Glangwili)

The inter-dependencies between specialties is so important that it does all hinge on the medical workforce (Withybush)

There are no generalists any more…they’re not training general surgeons or physicians; it’s about specialties within specialties (Withybush)

There’s a huge amount of work to do in Wales to get the medical workforce right (Withybush)

I don’t think we have any choice other than developing specialisms (Withybush).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.29 In the context of developing centres of excellence, some senior staff felt it is unrealistic not to recognise that Prince Philip not only lacks a full Accident and Emergency service, but also has a lesser range of other services:

Prince Philip does not have full maternity services, there’s no paediatrician on call and no facilities for children’s surgery (Glangwili)

Prince Philip is a specialist hospital for breast cancer and orthopaedic services – and these strengths need to be highlighted – while making the point that it cannot be excellent and specialised in everything (Glangwili).

4.30 Glangwili senior staff said it is positively undesirable to even aspire to have all services on all sites:

It is undesirable to try to have a service on every site – unless we can be sure of competency to delivery it (without a consultant on site) (Glangwili).

4.31 However, there was a clear recognition that in developing centres of excellence, the Board will need to take account of patient transport difficulties and to make suitable provision where particularly appropriate:

We have to recognise the problems with transport from Aberystwyth – and perhaps provide some accommodation for families (as in London hospitals) – then people will be more prepared to travel to specialist centres (Glangwili)

Hospital appointment times in Swansea and Cardiff don’t take account of where we live here – they can be at any time (Bronglais)

Greater centralisation is happening to save money – but people should not have to travel for a Clinic – some mental health patients come from Ceredigion for a routine clinic session – which might be on a weekly basis – (Glangwili).

4.32 Overall, the senior staff clearly felt that a workable and safe balance has to be found between patient accessibility on the one hand and safety and clinical excellence on the other. The more junior staff had reservations about concentrating services because: centralising resources would lessen the skills of staff elsewhere; patients would need to be moved for operations and returned for nursing care afterwards, which would be costly; patients might be returned prematurely from the centre to Virtual Wards in the community; and patients expect to get surgery near to home.

4.33 Nonetheless, many junior staff agreed with the creation of an orthopaedic surgery centre in the south of Hywel Dda – and some observed that:

Carmarthenshire has 11 orthopaedic surgeons (for elective at Prince Philip and for trauma at Glangwili) while Withybush has only five and does not have any ring-fenced beds (Withybush).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.34 Regarding breast cancer there was similar general recognition that:

Withybush has only one stand-alone consultant doing all the breast cancer surgery – so it would be best to centralise the future service at Prince Philip (Withybush)

Prince Philip is more set up for surgery there and they have bigger patient numbers there – and breast cancer involves fewer people travelling than orthopaedic surgery would. (Withybush).

4.35 Everyone we spoke to favoured keeping breast cancer services at Prince Philip – significantly because it is a centre of excellence:

The service there is second to none! And people do get after care here. People will have to travel for some things – if they are really specialised. But staff are worried about this as a precedent (Bronglais)

Breast unit is new and excellent – it has been running for two years with a good consultant and high technology and equipment and it provides a fast-track service for the whole of the HDdHB area – not enough recognition has been given to how good we are (Prince Philip).

4.36 Overall, while there was general agreement that breast cancer expertise and resources should be concentrated in one site, people felt that chemotherapy, rehabilitation and follow-up should be delivered as locally as possible

4.37 Regarding colorectal cancer many felt that the decision to centralise services has been taken in favour of Withybush because the hospital has already advertised for two additional surgeons (to make four in total) – and they added:

We have a good record and we are IOG accredited – so this would be a good place to centralise (Withybush).

4.38 However, those in Bronglais felt that:

It is undesirable to centralise colorectal services in Carmarthenshire and to take them away from here (Bronglais).

4.39 Overall, few wanted to judge between Withybush or Glangwili for colorectal cancer, but a significant comment was that:

The Board has to make a decision based on the facts and resources (Glangwili senior).

4.40 Regarding women and children’s services, there was also a recognition of the need for change:

We have to change to provide an overall, safer service (Withybush)

At all our hospitals there’s not enough births for training purposes. We have to change otherwise all the junior doctors would be removed from Hywel Dda (Withybush)

We don’t have complete consultant support here – there is a lack of anaesthetic specialist cover even here (Glangwili).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.41 Some senior staff stressed the need for specialisation in larger centres of excellence:

The Deanery will require certain standards and centres and it will be impossible to recruit to non-specialist centres. (Glangwili).

4.42 But there was recognition that the trust should take into account the problems of travelling for families:

We need to have support for families. The impact of centralisation is likely to be greater in a large rural area – so we need to provide some facilities for families in acute cases where the family base is very remote (Glangwili Doctor).

4.43 There was some opposition to centralisation of mental health services:

It would be wrong to centralise in one area – it would mean the cases all came to A&E (Bronglais)

We all need facilities for short term in-care (Bronglais).

4.44 However, some felt that a specialist centre would be a good initiative:

For a psychiatric intensive care unit the best site might be Carmarthen because it is more central. There’s no such unit at the moment – and people currently go out of the area – if they cannot be contained in the current general wards – and it is very hard to get outside beds in other Health Board areas (Glangwili)

We’re desperate for one site to be designated as a specialist unit…we’re sending people out now for short-term intensive care to Weston-Super-Mare (Withybush)

There’s nothing to argue with here – and we have been involved in developing the options (Withybush senior).

4.45 Staff acknowledged the difficulties of trying to define the best locations for acute medicine:

We’re used to having to travel for certain things already…like heart attacks to Morriston. We’ve got used to that very, very quickly. We’ve got used to the neurosurgery pathway going to Cardiff (Withybush)

It’s all about getting a quick diagnosis by senior decision-makers at the front end - and agreeing a pathway when you have that diagnosis. Having resident middle-grade doctors on site will help in that respect (Withybush)

4.46 There were calls to keep acute surgery at Bronglais, but the general view was perhaps that it should be based in Withybush or Glangwili because:

There cannot be a specialist service in Aberystwyth because of poor roads and difficult recruitment there (Glangwili).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.47 In general, while recognising the centres of excellence, senior staff outlined the need for some hard choices:

We really have “one hospital” spread across four main sites – and splitting specialities across the those sites causes problems. For example, Withybush is a long way from most of the population; it has not got a large population centre; getting there involves a lot of travelling; and, for recruitment, it’s not on that M4 corridor – so it’s never going to recruit easily – but it has many specialities, down there or in Carmarthen. The main specialities have to be located where most people are! (Prince Philip).

4.48 In this context, it is important to take account of the perspective of Bronglais staff – who feel that their hospital has a strategic location in mid and north Wales that is often overlooked when viewed from the south:

They are looking at everything from the point of view of the south – but we’re distinct! The Bronglais catchment area is much wider than they seem to realise – many of our beds are devoted to people Gwynedd and Powys (Bronglais)

We need an all-Wales perspective on catchment areas, distances to treatment and population sizes – the Health Board boundaries should reflect the areas we provide for (Bronglais)

Some specialist care is best given in North Wales rather than South – we need more cross- border collaboration with the North Wales Boards (Bronglais)

The risk is that we shall leave huge parts of Wales without a proper DGH – with acute surgery only on the north and south coasts of Wales (Bronglais).

Accident and Emergency Centres

4.49 Much of the discussion of Accident and Emergency services focused on Prince Philip – and generally those staff (at other hospitals) who were aware of the true nature of the current services at Llanelli did not propose enhancing the service – but they did think the current status of the so-called Accident and Emergency services should be made clearer to the public:

People just need to know what the service is now at Prince Philip! (Withybush)

4.50 At Prince Philip itself, the current situation was described in the following comments:

We have GPs on duty at night, but we get serious medical patients being admitted and staying in their beds (and in some cases coming in as overflow from Glangwili). The GPs get additional training and it works quite well, but technically it is only a minor injuries unit at night (Prince Philip)

Our preference would be to have a full A&E here – and acute surgery to match (Prince Philip)

Ambulance transfers are very slow (Prince Philip)

Patients from here do not travel to Swansea – we have to travel Westwards in reality except for the very specialist cancer and trauma services (Prince Philip)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

If we can get access to the A&E assessment, we do not mind being referred to a specialist centre elsewhere (Prince Philip).

An Urgent Care Centre here has to be 24-hours a day partly because it has to compensate for the difficulties of accessing GP services – appointments can be slow – you often cannot get through on the phone even to speak to the GP – I have even phoned for an hour on behalf of a patient as a CPN! The GP services are not user friendly (Prince Philip)

4.51 In terms of future strategic scenarios, there was general agreement that more minor injuries should be dealt with in primary care and that an Urgent Care Centre should be established at Prince Philip – while major Accident and Emergency centres should be maintained at Bronglais, Glangwili and Withybush.

Three A&Es seems the best option all round – if you don’t have it then travel times for ambulances would approach two hours and many other journeys would be lengthened.

An Urgent Care Centre is not an unreasonable situation – there cannot be an A&E because there are not suitable back-up services available there (Glangwili).

4.52 Generally, the staff felt that three major Accident and Emergency centres should be retained on the basis of:

Local risk – including industry and tourism

Travel times on poor roads

Travel costs to patients and the ambulance service.

4.53 In this context, there were some fears about the future of Accident and Emergency services generally:

There is a fear that all three will turn into minor injuries units – there is particular concern at Bronglais and Withybush (Glangwili).

4.54 But some were not so alarmed at the idea of some ‘centralisation’:

Glangwili is at the “start of the corridor” to the East. It might be plausible to have two – at Bronglais and Glangwili (Glangwili).

4.55 At Bronglais, though, many staff were emphatic that their Accident and Emergency should not be down-graded, but there were some complications acknowledged:

It is important that we keep A&E here – but we are not clearly told what is likely to happen (Bronglais)

The listening process has been alarming because it has raised radical options

A fully functioning A&E requires associated orthopaedic and general surgeons and an obstetrician – so we have to be able to recruit for the surgery positions – one is retiring in September but there is little time left (Bronglais)

Full A&E also needs paediatrics and proper theatres – but the existing theatres need major refurbishment (Bronglais)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

We need proper facilities to recruit the surgeons – they will not come for only day case facilities – they want to do major surgery (Bronglais).

4.56 Others had very different views of Bronglais Accident and Emergency capacities:

There’s not the volume of work in Bronglais A&E compared to the others. You haven’t got the workflow there to have sufficient specialist doctors, so it doesn’t make any sense at all to have a major A&E in Bronglais. Bronglais really is a run-down hospital in the middle of nowhere! (Prince Philip)

It makes sense to have the major A&Es where the majority of the population and logistically Carmarthen makes sense, if you’re having one. If things have to be centralised, then Glangwili seems the obvious choice. (Prince Philip)

4.57 There was general agreement that:

We’ve got too many hospitals trying to do the same thing for the population; we’ve got duplication of services. Anyone with an ounce of common sense would say we don’t need Prince Philip as a general hospital, but it is your biggest population in the whole of Hywel Dda. Publicly and politically it would be an issue! (Withybush).

Care Close to Home

4.58 The more junior groups seemed to suppose that the ‘care-closer-to-home’ initiatives are designed to improve the NHS financial balance sheet in the immediate future – and so they were sceptical on this basis, since they did not think it could save money immediately. In other words, many did not relate the plans for a shift towards primary care to the demographic context.

4.59 Overall, both senior and junior groups across HDdHB area approved of more care in the community in principle, but they were very worried about its effective delivery in practice – for a wide range of reasons (in no particular order):

Too many GP referrals to hospitals

Poor access to in- and out-of-hours GP services

Poor liaison between GP and Accident and Emergency services when co-located on the same site

Poor discharge management and patchy provision of follow-up care

Lack of 24-hour CRT and ART provision

Poor co-ordination between health and social services workers, even when co-located (with different procedures and separate IT systems)

Communications hubs not yet operating fully across the area

Rural areas providing particular difficulties for care in the community in terms of distances to travel which limit the numbers of patients to be seen within a shift

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Lack of sufficient funding

The need to get effective community care in place before reducing hospital services.

4.60 Many staff acknowledged that many Accident and Emergency attendances are inappropriate and agreed that many hospital admissions are strictly unnecessary. For example, staff worried about the effectiveness of the Out-of-Hours community care services for chronically ill elderly patients needing basic care services.

We get lots of calls for admissions late on Friday because GPs don’t want to risk having to do call-outs at the weekend! There has to be an effective over-night service (Withybush)

People who should go to their GP just come to casualty, they just go to wherever is the quickest access. Part of the problem is that GPs are not accessible 24/7 which is ridiculous. We’ve got shops that we can access 24/7, and if you’re ill out of hours you don’t want a lesser service. I would go to a GP over a hospital if that was available, but often there’s no other option. (Prince Philip)

The Out-of-Hours service is very slow – it is possible to wait for 8 hours (Prince Philip)

GPs will not accept a referral from A&E unless they first make a phone call via the triage – we need to change the system – at the weekend there is only 1 GP and s/he might have to go out to see patients (Bronglais)

Out-of-Hours call centres will refer to 999 for all chest pains (Bronglais)

The Out-of-Hours will also set a time limit for a GP to phone – but if he doesn’t ring within the time – so patient goes to A&E or dials an ambulance (Bronglais)

People also go to A&E if no GPs appointment is available (Bronglais)

Some GPs send a disproportionate number of paediatric cases into the hospital – children and adults are sent in to hospital with tonsillitis or constipation! They come for assessment but they expect to be admitted (Bronglais).

4.61 Overall, there was a lot of doubt about whether better care closer to home could actually be delivered – and many stressed that elderly people with chronic conditions need better basic care services at their homes. Their worries were not about the principle of care closer to home but the practical implementation: they worried about whether there would be sufficient staff to provide overnight and weekend cover and whether there would be an effective management system to get the right care to the right people at the right time. For example:

Virtual Wards are an excellent model of care but it needs really good resources to make it work effectively (Withybush)

There are 27 people working [in the Carmarthenshire HUB] but there is no one to attend people at the weekend! Where are the community teams to refer people to? Are they in place in Carmarthenshire or will they be put in place? (Withybush)

We only have three chronic condition nurses in Pembrokeshire; we are looking at extending the hours of the district nursing service to 8-8, but it needs to be 24 hours (Withybush)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

At night patients can have personal care problems, like catheter problems or needing continence pads if they cannot get to the toilet – and such patients are told to “pee in their pants” and are left alone for long hours – but this is undignified and unhealthy (Withybush)

Many care services are inadequate in the time spent with the patients – making it impossible for them to feed the patient in the time allowed – and meaning that they might be put to bed at 6pm – so people might be alone from 18.00 to 11.00! (Withybush)

They are doing well, but the acute response teams don’t provide a 24-hour service – there are no acute response teams available to go out and fit or adjust catheters at night – so the service is not 24-hour but really up to about 10pm when the Acute Response Teams go off duty – so then the GPs cover (with one GP from midnight for the whole of Pembrokeshire!). There are many more emergency Vets available at night than nursing Acute Response Teams! (Glangwili).

4.62 Some staff felt that more could be done within the community if there was greater recognition of other care professionals and the voluntary sector:

The clinical strategy needs to become less clinically/medically driven and to recognise that successful services can be delivered by a wider range of professions – for example, half the routine follow-up outpatients appointments are unnecessary – they could be provided by nurses and other professionals (Glangwili)

Acute Resource Teams are needed, but general nursing teams could also do a lot while working alongside the voluntary sector – e.g. for palliative care (Glangwili).

4.63 A senior member of staff at Glangwili expressed concern that: Unless we’ve got a far better integrated social and health model it won’t work:

The different health and social care teams have different models and resource bases in each of the three counties – and it is very hard to share information (Glangwili)

It is proving very difficult to manage the health and social services interface – they have different IT systems: even though the health people are now based in the County Council building they cannot access each others’ data The fact that H&SS are in the same building does not mean they are really integrated! (Glangwili).

4.64 The lack of joined-up working between GP’s and Hywel Dda is also considered a barrier:

GPs are run like private businesses and do not easily interface with the HDdHB in terms of planning integrated care in the community – they simply want resources to deliver specific clinics or services for payment – with a few exceptions (Glangwili).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.65 Yet, GP’s are viewed as being the best placed to integrate community services and are thought to have a central role in the development of Community Hubs:

GPs have an overall picture of what patients need – and they need to direct patients to the most appropriate routes to effective care – which might be through community clinics or staff going into the community (Glangwili)

The GP practice is the centre of a community’s healthcare – so why can’t everything be provided from there? (Withybush)

It’s about having the hub with the expertise and having the pathways in place across the organisation (Withybush)

The communications hub should be part of a wider community hub…probably based around a large GP Practice (Withybush).

4.66 Staff agreed that care in the community needs funding, planning and managing properly. However, even with resources, geography provides challenges to care in the community:

The model of care in the community would work better in a more compact community, if it’s spread out like ours is then it is very difficult because you need more staff and they see relatively few people because they have to travel so far between cases (Prince Philip)

The Acute Response Teams can only deal with about 4 cases a day due to distances to travel – it is a costly service – so we need to prescribe the right antibiotics that can be administered once a day – the time on the road is considerable (Bronglais)

The problem is that the Acute Response Teams are quite limited – and they have to try to cover very large areas – for example, three house visits can be very widespread (Glangwili).

4.67 That said, an alleged increase in administrative duties has limited the number of patients seen in the community even further:

The Community Mental Health Teams’ records are constantly audited and the process of record keeping is laborious and slow – so it takes us away from the community – I can only see two people a day – it’s not the travel time but the administration in the locality (Prince Philip).

4.68 As we have said, the principle of care closer to home was readily accepted, but at all levels staff were worried about the current standards of the care services as delivered in the community – for example:

People are discharged and no one takes an interest in them. There is an issue between hospitals and GPs – who don’t communicate well enough. People can be discharged from hospital and then just fall into a big hole; and no-one knows who is responsible (Prince Philip).

Having gone via Careline+ to get a referral for a Fall-assessment for an elderly person, it took five weeks for the person to be seen – and I had tried the GP, other community services and etc – so referrals are not straightforward even when you know the system. A lot of the careline service is still aspirational (Glangwili)

Prince Philip is likely to lose 20 acute medical beds in order to put more into community services – but there are no community services in place to substitute (Prince Philip).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.69 Based on the current problems related to community care, it was the view of staff that hospital services should remain intact until community services are properly resourced and managed:

There is not enough care in the community facilities and provision – there are already problems that mean we need more community services (Bronglais)

We should put the community care in place and then demonstrate that hospital admissions are unnecessary. We need to improve care closer to home now – we cannot remove beds until we have adequate care in the community (Bronglais)

We need to create adequate community structures, but this needs proper pump priming to get it going properly. You cannot withdraw acute services without having proper community services – but funding is threatened. (Glangwili)

Care closer to home has to be the start of the whole process – it has to be in place before changes are made around it –but there are now less staff in the community than some years ago – and Social Services are disorganised (Bronglais).

The Problem of Demand

4.70 Some senior staff doubted that care closer to home or different forms of treatment can really reduce demand on hospitals:

Care in the community cannot easily free beds. They say, “Let’s look at vascular-intervention work so instead of somebody having surgery on their aorta they put in a stent which is less invasive, costs less, and frees time”. But it doesn’t free up anything because there are hundreds of people waiting to come in for other things! It just means you can do more patients and people wait less. It takes a long time to clear that back log of people and by the time you start to clear it, technology has moved on (Prince Philip).

When I first came here we only did hip and knee replacements, now we do ankle replacements, shoulder replacements. We have improved the turnover for these so that they only stay in for a couple of days, but we do more and more of them. Even things like diagnostic tests have moved on and the number of CT scans has hugely increased. Why are we doing so many? Because we are doing things that we couldn’t do before; we’re improving our healthcare, but there will never be sufficient resources to meet demand (Prince Philip)

There is also training issues because doctors who are coming out of training now are more test- dependent: whereas before we would make clinical judgements to patients home, now we send them for a CT scan and admit them if there is any doubt because there’s medical legal litigation and people are worried if they don’t (Prince Philip)

More prevention work will not reduce demand on services. Living a healthier lifestyle may prevent me from having heart disease, but eventually I will get ill because I will get old and my joints are still going to fail, my eyesight’s going to go, I’m going to get dementia. The longer I live, the more things I’m going to have wrong with me. Everybody dies and has diseases sometime before they die. An ageing population causes its own problems (Prince Philip)

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

The first thing a GP will do if someone comes in with chest pains is to send them to hospital and they will be admitted overnight because the doctors that are dealing with them aren’t too sure (Prince Philip).

Listening and Engagement Process

4.71 Most staff were critical of the Board’s listening and engagement process for several main reasons: Raising public and staff anxiety by appearing to put too many complex (and in some cases unreal) options on the table without full explanations

Nonetheless, having already made up its mind

Being out of touch with community concerns (Llanelli)

Running some meetings with the public and staff poorly

Wasting money on DVDs.

4.72 All staff recognised the difficulties of determining and explaining the best locations for specific services – but some senior staff (particularly at Glangwili) were optimistic that people could be rationally persuaded of the general case for change if the following were explained clearly: The nature and limitations of current services and their lack of resilience were explained (for example, the actual status of Prince Philip’s Accident and Emergency)

The implications of small case loads, small teams, lack of back-up support and recruitment difficulties for patient outcomes

The benefits of travelling to centres of excellence were made clear

That diagnostic and follow-up care would continue to be provided locally

That there would be provision to assist patients and their families with travel and accommodation in needful cases (for example, children’s surgery).

4.73 Many staff had relatively negative views of the listening and engagement process – generally because they felt that HDdHB has already made up its mind and/or some of the options mentioned are not genuine, they’re just listed but would never happen. Indeed, this was the case when presented with the options for breast care services:

The breast care services are bound to be centralised at Prince Philip – it is not credible to put them at Withybush – they should just say “we are selecting Prince Philip for the breast cancer services” (Bronglais).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.74 A member of staff at Prince Philip was concerned that little attention has been paid to their hospital and we seem to be an afterthought. Detailed explanations would have been appreciated by many staff who were eager to understand the rationale behind the options:

The interesting thing is someone’s obviously thought the options through, but there is no background information to see how they have arrived at them. The information that we get isn’t brilliant, it hasn’t been communicated (Prince Philip)

The meetings don’t give clear answers (Bronglais)

They should explain the rationale for particular options (Glangwili).

4.75 It is argued that HDdHB’s failure to present thorough reasoning behind the options and the over-reliance on the media for information has led to increased anxiety and uncertainty about the future which in turn as led to concerns:

No one knows what’s happening (Bronglais)

People are worried about losing their jobs, having to move etc. What they don’t know by reading and going to meetings they’ll make up or get through word of mouth or the press…that’s the main problem we’ve got (Withybush).

4.76 However, some senior staff at Withybush felt that the lack of knowledge amongst staff was due to their lack of engagement with the process rather than the efforts made by HDdHB to inform:

It feels like a general lack of interest amongst the staff – they aren’t taking opportunities to find out what’s going on (Withybush)

I’m struggling to understand the way people are reacting to what’s going on…I think we’ve lost the focus around this being about providing the best possible health service in the current climate. The fact that ‘no change is not an option’ has been lost and we haven’t got under what that means (Withybush)

I find it very difficult to understand how members of staff feel it’s right to go into other domains and criticise the Health Board and yet are not prepared to engage within the process and be constructive (Withybush).

4.77 Besides these main points, some more junior staff complained about having too much information and feeling that they were not supposed to question the plans. In Withybush for example, junior staff also complained said that:

There has been a lot of organisational change in the last few years – so it is hard for us to know much about the new Management Team – we went to a meeting and did not know who most people were (Withybush).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

4.78 Perhaps due to the size and complexity of HDdHB, many staff said they feel remote from the top management:

It feels like a massive management structure that doesn’t add a lot of value in my mind. There’s many tiers of people that you never meet, you never even see. When we merged as an organisation it was to cut costs, but that hasn’t happened because they have put in an extra layer of management (Prince Philip.)

4.79 While the listening and engagement process has been open in many ways, some senior staff still feel unsure of how their comments would be received by senior management – for example:

We broadly agree with the Board’s strategy – but not its delivery – but I feel unable to challenge the Board’s approach to these matters – I would be uncomfortable about possible ramifications. The new executive team appears to diminish the achievements that have been made in recent years – as if nothing has been done before them (Glangwili).

4.80 These concerns seem to have been encountered by some staff who felt that when they had approached the Board, in both the staff and public events, they were dismissive of their comments:

They can seem patronising (Bronglais)

The staff session here was patronising or derogatory as staff tried to speak – many staff were offended by their self-righteousness but they didn’t want to listen (Prince Philip).

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5. Submissions

5.1 Submissions were received from professional, political, interest, voluntary and community groups, residents and staff. There are over 500 submissions, split between those sent direct to ORS (86), those received by HDdHB (271) and those sent direct to the minister Lesley Griffiths at the Welsh Government (212) and now passed on to ORS. HDdHB has reviewed all submissions and has responded to many of them. Stakeholder Submissions - Selected Summaries

Introduction

5.2 The HDdHB’s listening and engagement process attracted considerable attention and numerous submissions were made by stakeholders and members of the public – some of which were detailed and lengthy. In total, 570 were received by either HDdHB and/or ORS.

5.3 It is not feasible or necessary to include all the submissions in full in this interpretative report, but all have been noted by HDdHB. We have summarised the main themes and topics of the general submissions in later sections of this chapter; but (given the importance of the issues raised) we have summarised a selection 19 stakeholder submissions immediately below – namely, those from: Hywel Dda Community Health Council, Pembrokeshire Locality Ceredigion GPs’ Forum Ystwyth Medical Group Ceredigion Local Service Board Ceredigion Voluntary Sector Representatives on the Ceredigion CHC Three Ceredigion County Councillors on the Ceredigion CHC Ceredigion Partnership Forum – staff side representatives Hywel Dda Partnership Forum – staff side representatives NHS Confederation Angela Burns, AM Paul Davies, AM Elin Jones, AM Stephen Crabb, MP Simon Hart, MP Elfyn Llwyd, MP

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Save Bronglais Campaign – separate letters by County Cllrs J Michael Williams and Sylvia Rowlands Save Withbush Action Team (SWAT) Committee for the Improvement of Hospital Services (CIHS-Sosppan).

5.4 In these summaries we have sought a balance between brevity and detail: it has not been possible to include all the detailed arguments and points made by the respondents – but the following sections are indicative of the material submitted to HDdHB. The full submissions have been studied by HDdHB and many of them have received detailed replies from the Board. (We have seen many of HDdHB’s replies, but it is not appropriate to include them in this summary.)

Hywel Dda Community Health Council, Pembrokeshire Locality

5.5 The CHC has been concerned that the communications about the potential changes to HDdHB’s services have been poorly handled and have raised public anxieties. The Council is concerned that the HDdHB is giving a negative impression of some current standards and would prefer to celebrate areas of success and good practice while recognising where improvements need to be made.

5.6 Looking forward the CHC expects the final proposals to reflect a needs assessment of the problems of delivering high standard health care in rural areas, with economic and clinical evidence, costed options, the pros and cons stated, and reviews of the possible outcomes of the options. The Council would like to be assured that clinicians in all the disciplines have been involved in the planning process.

5.7 Overall, the Council is concerned that the centralisation of services will increase the distances travelled by patients and their families. The CHC also applauds the HDdHB’s determination to “meet quality and safety standards" and recognises the recruitment difficulties.

5.8 The CHC welcomes the prospect of a full Accident and Emergency service in each county with the essential backup services and related Core Services. The Council would like emergency surgery to be retained in full, both as an essential life-saving service and to ensure the continuance of related core services, including a full night-time service (required at both Bronglais and Withybush Hospitals).

5.9 The CHC believes that: Proposals to enhance community care as a means of reducing unnecessary hospital admissions and long stays should be realistically costed and subject to greater clarity Examples of best practice from other rural areas should be studied Changes should be “hands on” staff-inspired to secure involvement and cost effective improvements.

5.10 The CHC supports: The further development of colorectal surgery in each county with surgical units working as an all-Hywel Dda team The development of a single centre for complex orthopaedic surgery, providing high standard elective hip and knee replacements remain at Withybush, together with the essential backup services

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

HDdHB’s assurance that consultation on proposed moves of service would be made well in advance and that change should only take place when the infrastructure support is in place An early announcement of plans to confirm the long term future of services.

Ceredigion GPs’ Forum

5.11 The majority of general practitioners in Ceredigion support the principles underlying the Board’s strategy, but want to ensure equity of access to health and social care and are concerned about distances and diagnosis-to-theatre times in life threatening conditions.

5.12 They support delivering care closer to patients’ homes and strengthening primary and community care, but they argue for increased resources for primary and community care.

5.13 In the context of GP retirements, they favour the continuation of the GP Vocational Training at Bronglais Hospital.

5.14 The GPs also argue for: Adequate transport in the proposed new model The effective development of the “Communication Hubs” as single points of access Increased use of telemedicine (while recognising its limitations) Developing the role of pharmacists Option 3, for an Accident and Emergency service at Bronglais Acute Medicine – the need for paramedics to transport patients directly to the most appropriate service Acute Surgery and trauma - the model for middle grade staff surgeons to provide surgical services overnight at Bronglais with consultant cover from a centre in Carmarthen would provide a reasonable option so long as it is possible to recruit high quality doctors at this grade Trauma – Glangwili and Bronglais Hospitals to provide trauma services Planned Care – with General Physicians who have generalist clinical skills working across the traditional secondary and primary care boundaries In-patient elective orthopaedic care – the continued provision of orthopaedic services at Bronglais Hospital with more complex cases being treated at Glangwili or Whithybush Hospitals Cancer Services – the current balance of services between Bronglais and Prince Philip Colo-rectal cancer – the continuation of colo-rectal surgery in Bronglais Hospital and Haverfordwest Children and maternity services – scenario 2.

5.15 The GPs would like further clarification about: Resources for extended access to GPS Mental Health Specialist Units.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Ystwyth Medical Group (YMG)

5.16 The group accepts that some specialised services will need to be provided in large hospitals, but does not accept that everyday services (including cancer care) should be provided only in large centres.

5.17 They accept the aim of reducing avoidable hospital admissions and providing care closer to home, but believe that extra resources will be needed for primary care to achieve this. They also argue for:

GP training in Aberystwyth Maintaining surgical skills in Bronglais (including for colorectal cancer) Maintaining emergency care in Bronglais The equal provision of secondary care services in Wales irrespective of where patients live More resources in order to deliver the proposed extension of primary care hours and more chronic disease management.

5.18 The group supports:

Plans to improve access to specialised mental health care services, but they want less bureaucracy accessing these services The provision of acute medical services at Bronglais (and believes patient transfers out of area should be on the basis of clinical need rather than bed availability) The continuation of trauma services in Bronglais.

5.19 They oppose:

Bronglais being an urgent care centre and believe it should be developed as a major centre Acute surgery services being developed away from Bronglais because such downgrading will mean patients cannot be treated adequately.

5.20 The group would like specialised orthopaedic services in specialist beds to be developed within Bronglais.

5.21 They would also like the more common cancers to be managed in local hospitals and feel that the service their patients get is as good as in a major centre. They feel the current situation for breast cancer services is satisfactory, but strongly disagree with the move of colorectal services to Carmarthen or Haverfordwest, partly because the removal of the surgical cancer service would lead to the loss of accreditation and partly because the number of cases that are undertaken locally is nearly that required by the international oncology guidelines. They feel that patients in the hinterland between north and south Ceredigion should be encouraged to come to Aberystwyth so that the numbers can be maintained above the minimum.

5.22 The group approves of the intention to provide care for children closer to their home, but feels it is important to maintain current services for inpatient care.

5.23 They accept that the maternity services need to meet the requirements of the Royal Colleges and also believe that a local consultant-led obstetric services must remain for those patients for whom it is

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

appropriate. They also believe that gynaecological services should remain at Bronglais to ensure that consultants can be attracted to work there.

5.24 While seeing the challenges of providing a local paediatric service, the group feels that such services should be developed in Aberystwyth.

Ceredigion Local Service Board (LSB)

5.25 The Ceredigion LSB felt it was difficult to comment on many of the specifics at this time, but will make a detailed response during the formal consultation period.

5.26 The LSB believes that Bronglais Hospital should be developed as a centre of excellence for rural medicine, including both medical and surgical services – which would improve recruitment, particularly if incentives were offered for clinicians to work at Bronglais. The LSB challenged the consultation document’s:

Travelling time estimates Limited references to mental health services Statement that trauma or seriously ill patients do not need to get to the nearest hospital as rapidly as possible.

Ceredigion Voluntary Sector Representatives on the CHC

5.27 The group criticised some aspects of the DVD produced by HDdHB and stressed the contribution that the third sector is making to hospital discharge services and recommended that Hywel Dda should approach these groups for advice on service design and delivery.

5.28 There is a need to address advocacy support in the community, particularly for older people. The voluntary sector has proposed a full-time almoner, provided and administered by the voluntary sector and would like to know if HDdHB would fund such a third sector scheme.

Three Ceredigion County Councillors (on the Ceredigion CHC)

5.29 Cllrs Alun Lloyd Jones, Paul Hinge and Gareth Lloyd expressed their lack of confidence in HDdHB’s commitment to the Bronglais catchment area. They feel that the reorganisation of healthcare is simply a cost-saving exercise and that Ceredigion’s representation on the Board has reduced as a result of the loss of the Ceredigion Health Board. They believe the current Board is following a WG agenda and is not genuinely accountable for its actions to local people.

5.30 The three councillors believe that the services offered by Bronglais should be expanded on the basis that it is the only DGH between the A55 corridor in the North, and the M 4 in the South. In particular they oppose the transfer of abdominal and colorectal surgery to Withybush or Glangwili. They favour more care closer to home as a worthy goal, but argue that the infrastructure for such care is not yet in place.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Ceredigion County Partnership Forum – staff side representatives

5.31 The Staff Side representatives of Ceredigion Partnership Forum criticised the delay in the Board meeting staff and the questionnaire used in the consultation. They were disappointed with the options presented in the clinical services strategy because of the potentially negative impacts on the access to healthcare.

5.32 They also complain that the engagement of senior medical staff from Ceredigion was not on an equal footing with medical staff from Carmarthenshire. They also say that appropriate staff side inputs were not sought.

5.33 They believe the plan fails to take into account the healthcare needs of the Bronglais area, including demand and capacity planning for both elective and emergency care for patients from South Gwynedd and Powys. They say the aim of no one being more than 90 minutes from major trauma, complex medicine, complex surgery, specialist cancer, neonates, complex cardiac and neurosciences could not be met from Aberystwyth and Bronglais’ catchment area if key services are centred on Glangwili Hospital; and elderly people are reluctant to travel such distances. The proposal to remove services from Bronglais contradicts the ethos of keeping care local.

5.34 The staff side representatives say there is no detail or funding information on the community services referred to in the plan.

5.35 They argue that too little attention has been paid to the third sector, equality and diversity groups and staff in assessing the impact of changes.

5.36 Despite promises to the contrary, they say there has been no investment in Aberaeron (despite £7milIion being allocated from the Front of House scheme to build the community facility), no investment in essential major inpatient theatres, and consultant job adverts refer only to services in Carmarthen/Withybush. It appears that a decision has been taken not to replace the Bronglais colorectal consultant who is scheduled to retire – even though Bronglais is the obvious choice to develop a centre of excellence for endoscopy and colorectal surgery.

5.37 The representatives say they have lost confidence in Hywel Dda Local Health Board’s commitment to support staff in delivering the services we provide locally.

HDdHB Partnership Forum – staff side representatives

5.38 The trade union representatives were concerned that services seem to be moving around Carmarthen and there is a possibility of increased workloads for staff. They recognised that Prince Philip does not offer a full Accident and Emergency service, but further changes there would affect acute medical services. In Pembrokeshire staff did not know what was happening are afraid for their jobs, worrying that they would have to move home or be faced with the expense of travelling. Ceredigion representatives criticised the on-line questionnaire as being designed to give the answers the Health Board wants. There were many concerns regarding possible redundancies or having to travel to Withybush or Carmarthen. Community services cannot cope with the new additional expectations there had been no new investments. The representatives said that District Nurses have to make 15 or 16 home visits per day – which is almost impossible.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.39 The representatives said that they knew that neonates was changing to one site and it was a big concern, but no-one was being told what was happening. The representatives said that the general impression is the services will be centralised at Glangwili and that the public and staff were alarmed by this. People need to be told what is not changing.

Welsh NHS Confederation

5.40 The Welsh NHS Confederation wrote to report its discussions with local politicians who are concerned about their constituents’ worries about the review of hospital services.

5.41 Some feel that the Health Board is too focussed on Glangwili and Withybush and that Prince Philip is being side-lined because the Board is too rural-focused and does not appreciate the needs of urban Llanelli.

5.42 The Confederation reported concerns about the closure of Ward 5 at Prince Philip and about the removal of other services. It also said that local politicians are concerned to keep the current Accident and Emergency services at Prince Philip – at least to the extent that the GP-led Out-of-Hours unit should not be replaced by a nurse-led Out-of-Hours service.

5.43 In relation to the listening and engagement process, the Confederation reported that, according to local politicians the Board’s DVD had not been appreciated or widely viewed and that there had been too few events in Llanelli.

5.44 On a positive note, he was very supportive of a recent visit to the Acute Response Team and felt that more should be done to publicise the service. He also talked about very good examples of breast, stroke and dementia care at Prince Philip.

Angela Burns, AM

5.45 Angela Burns, AM, wrote to stress that Pembrokeshire is a large rural area with poor transport links and poor access to public services, and has an aging population with a large summertime increase in numbers. Future hospital services should take account of these basic facts, but the impression is that many services are disappearing from the west entirely.

5.46 In this context, she believes the following are core services that should be consultant-led at Withybush:

Acute Medicine (including Cardiac Care) Acute Surgery Accident and Emergency Obstetrics and Gynaecology Paediatrics Anaesthetics Intensive Care Orthopaedics.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Paul Davies, AM

5.47 Paul Davies, AM, wrote to say that he has protested repeatedly in the Senedd about the transferring of services eastwards from Pembrokeshire on the grounds that journeys from Pembrokeshire to Carmarthen can be lengthy. He points out that Pembrokeshire has an ageing population which increases in the summer due to tourism.

5.48 In this context, he believes the following are core services that should be consultant-led at Withybush:

Acute Medicine (including Cardiac Care) Acute Surgery Accident and Emergency Obstetrics and Gynaecology Paediatrics Anaesthetics Intensive Care Orthopaedics.

Elin Jones, AM

5.49 Elin Jones, AM, wrote to express concern that a 40% reduction in beds in Tregaron Hospital was apparently being treated as an ‘operational decision’ rather than subject to full consultation.

Stephen Crabb, MP

5.50 Stephen Crabb, MP, wrote that he welcomed HDdHB’s listening and engagement exercise because transparency and consultation are essential to break down the apprehension which many people have with regards to any proposed changes to the health services they currently enjoy.

5.51 He supports the campaign to retain services close to the local community in Preseli, Pembrokeshire, especially those provided at Withybush because it is vital that all residents have good access to important health services locally. He accepts that ‘no change’ is not an option in light of the immediate and longer term challenges that the Health Board faces, but is worried that the Board is perceived to be pressing ahead with key changes and some important services have been withdrawn from Withybush in recent years.

5.52 He stresses that Withybush serves a large rural area with important maritime and energy industries and is also a busy holiday destination. He compares these facts with Carmarthen, which is a short distance from Morriston and Singleton hospitals, and opposes any transfer of key services to Glangwili on the grounds of remoteness from Pembrokeshire people. He fears that the emerging clinical services strategy may worsen access to services for Pembrokeshire residents.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.53 In this context, he believes the following are core services that should be consultant-led at Withybush:

Acute Medicine Acute Surgery Accident and Emergency Obstetrics and Gynaecology Paediatrics Anaesthetics Intensive Care Orthopaedics.

5.54 He believes closer access to care in the community and improved patient safety are certainly desirable, but local people need more detail on how these changes will be delivered.

Simon Hart MP

5.55 Simon Hart, MP, wrote to express concern over the closure of the Minor Injuries Units at Pembroke Dock and Tenby because the two communities will be left without any local emergency provision.

5.56 He was also concerned that ambulances no longer take minor injuries to hospital and questioned how the elderly or those without a car will now get to Withybush for treatment. He asked why there was no consultation on these closures and how Withybush Accident and Emergency will cope with the increase in presentations.

Elfyn Llwyd, MP

5.57 As the representative of South Meirionnydd, Elfyn Llwyd, MP, wrote that the area served by Bronglais Hospital is enormous and to express his concern about any cuts in the services currently offered – on the basis that people from extensive rural areas would have difficulty travelling to Glangwili Hospital.

Save Bronglais Campaign – letters by County Cllrs J Michael Williams and Sylvia Rowlands

5.58 On behalf of the Save Bronglais Campaign, County Cllrs J Michael Williams and Sylvia Rowlands complained separately to the Minister for Health and Social Services that two public meetings in Machynlleth had called on the Minister to intervene in the clinical services review to ensure equitable access to healthcare across Wales – on the grounds that HDdHB is not the appropriate body to determine the future of Bronglais Hospital alone. They both reported that the public meetings supported the letter of no confidence from senior medical staff at Bronglais.

5.59 They both say that the strategic review of Bronglais’ surgical role has ignored that the hospital serves large number of patients in Powys and south Gwynedd and alleges that Hywel Dda has failed to engage with Powys and Betsi Cadwaladr Health Boards in relation to BrongIais' regional role.

5.60 They add that, in contrast to Bronglais, the hospitals along the southern corridor are within easy reach of each other, making rationalisation feasible without compromising access.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.61 They both report that the meetings rejected the listening and engagement questionnaire because the way the questions are phrased prevents them from expressing their views effectively; and they both end by repeating the call for the Minister to take over the review and prepare a plan that provides for Mid-Wales which provides for the needs of the people of Mid-Wales in Mid-Wales.

Save Withybush Action Team (SWAT)

5.62 The Chair of SWAT, Chris Overton, argues that the mantra "No change is not an option" is just management speak for wanting to make the savings that the Welsh Government has imposed. He protests that HDdHB has been running down every hospital except Glangwili for some time.

5.63 He argues that the demographic, technological and recruitment issues have been exaggerated as difficulties – or, in the latter case, are due to the Health Board allowing units to become understaffed and not trying to recruit hard enough.

5.64 He believes that there is an underlying intention to centralise services in Glangwili and dismisses the Welsh Government’s recently published "National Case for change" as a PR exercise.

5.65 The SWAT preferences are to maintain the status quo or (if that Is not possible) to merge the Hywel Dda and Swansea Health Boards to create a more sensible solution – which would both allow Withybush to become the main secondary care facility in the South West and also make Glangwili’s position less significant given its proximity via dual carriageway and motorway to Morriston. He says that in principle the site could be sold for social housing. In this context, he proposes that Prince Philip should be enhanced in medicine, surgery, orthopaedics and perhaps the development of a midwifery- led unit until Morriston’s capacity is increased.

5.66 In a meeting between SWAT and senior members of the HDdHB some topics were reviewed in further detail. For SWAT, three representatives argued that: HDdHB area would be more effectively covered by two lead hospitals, Bronglais and Withybush, with one subsidiary hospital in Carmarthenshire, that would also be served by Morriston 24-hour Accident and Emergency and Emergency Surgery services should be maintained in Bronglais and Withybush – but the new developments at Glangwili seem to conflict with this There is a danger that services may have to be withdrawn by default if recruitment is not addressed and existing doctors are allowed to feel their positions are insecure The HDdHB area deserves extra funding due to its rural nature The ‘Your Health Your future’ discussion document seems to suggest that current services are sub-standard While colorectal cancer could be managed at Withybush or between Glangwili and Withybush, there is a need for 24-hour emergency surgery at Bronglais – which could be achieved through the colorectal cancer MDT, making it possible to maintain surgical skills and training there, and to provide a 24-hour emergency service to support the Accident and Emergency Orthopaedic surgery at Withybush should continue to include elective hip and knee replacement for otherwise surgeons would be unwilling to work there.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Committee for the Improvement of Hospital Services (CIHS-Sosppan)

5.67 The chair of CIHS-Sosppan, V.B Hitchman, wrote to the Minister for Health and Social Services to report a Vote of No Confidence in the Hywel Dda Health Board at a large public meeting in Llanelli on 16th February, 2012. The primary reasons for the vote were the Board’s alleged: failure to meet the health needs of Llanelli and the surrounding areas of population; reduction in hospital and community beds and services by stealth and without full and proper consultation; reduction in accident and emergency services at Prince Philip Hospital; failure to do proper risk and impact assessments; failure to properly consult staff and clinicians in respect of changes, poor internal and external communications; lack of transparency; and failure to attend public meetings to discuss the concerns of the public. He reported that the same meeting also proposed that the issues should be debated in the WG with a view to alternative leadership being provided within the Hywel Dda Health Board.

5.68 Since then, the CIHS-Sosppan has also submitted a lengthy and detailed discussion document entitled “Engagement Proposals: An Alternative View” (April 2012) that includes considerable background material in several substantial appendices. The document (referred to below as ‘the report’) sets out alternative proposals for the development of healthcare in Llanelli and the Hywel Dda Health Board region. It seeks to meet the clinical priorities while providing ease and speed of access to unplanned needs as in the case of Accident and Emergency Services. It is possible to include only a summary account here, but readers are encouraged to read the full report.

5.69 The report reviews the historical background to what it calls the flawed plan for centralisation and Accident and Emergency provision in the context of population data for the area. It says that, following the creation of Hywel Dda LHB, many services were removed from Llanelli to Glangwili. Compared with when it opened in 1990, the hospital has contracted considerably: Accident and Emergency services have been reduced to a limited service; and the following services have been removed: surgical emergencies; acute medicine; cardiology; trauma; children; head injuries; maternity; gynaecology; ears and nose; throat and eye; post mortem; and more recently Ward 5 has been earmarked for closure and orthodontics has been removed.

5.70 Prince Philip has been run down, but the report says that if the hospital budget was allocated fairly, on the basis of population, then the greatest spend would be at Withybush, with Prince Philip second, followed by Glangwili and finally Bronglais. It says that the policy of centralisation means that every hospital apart from Withybush is disadvantaged. This seems particularly inappropriate in relation to Prince Philip, for Llanelli has more than a quarter of the Hywel Dda population.

5.71 The report’s general complaint is that these changes have increased the distances that Llanelli people have to travel for medical services withdrawn from Prince Philip; and the more particular complaint is that the limited Accident and Emergency services are further threatened. The report argues that Glangwili is unable to cope with additional Accident and Emergency demand and that the centralisation of Accident and Emergency services there is not feasible.

5.72 In this context, the report lists alleged failures of the system, including: patients waiting in Accident and Emergency at Prince Philip overnight because there is no room for them in Glangwili or waiting for ambulances after having triage; ambulances travelling from Aberystwyth to Llanelli to transfer patients to Glangwili; ambulance crews taking patients to Glangwili rather than their requested Prince Philip; people being discharged late at night in Carmarthen and having to find their own way home; and the long times and costs of travelling to appointments at Glangwili.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.73 The report accepts that change is essential, but centralisation is not the answer. In particular the report objects to what it calls the imposition of an unproven UCC (without an adequate and local Accident and Emergency at Prince Philip) increases risks to patients in Llanelli and is of great concern. It says that virtual wards are unproven and wasteful due to the unproductive travel time involved for professionals. The report also says that current plans put too much reliance on care being provided in the home by relatives or friends; and it doubts how well the use of GPs and specialists will work in practice.

5.74 The report welcomes the proposed use of technology, but has concerns about the implementation: it says the health and social services linkages are vague and do not allow for carer support, convalescence, rehabilitation, respite or adequate domiciliary care for either our disabled or elderly; and it criticises the lack of detailed costings.

5.75 Having criticised the HDdHB ideas, the report outlines an alternative approach – in which the creation of centres of excellence is tempered with local provision for unplanned Accident and Emergency services. In this context, it says that, with four district general hospitals in a large rural area, Hywel Dda has inherited a ‘poisoned chalice’ - though it does not spell out the implications of this phrase.

5.76 Anyway, the report outlines what it calls the ‘building blocks’ of a solution:

Four DGHs all providing Accident and Emergency services Excellent public, private and third sector transport links 24 hours per day Clinical centres of excellence within the hospitals Separate convalescence/rehabilitation units attached to the hospitals Respite and support in the community for carers, vulnerable elderly and the disabled, run by the County Councils and including: Day Centres Luncheon Clubs Meals on Wheels Carer Support in the home Residential Respite Surgeries and Community Hubs High quality regulated and inspected domiciliary care State-run residential care homes for the elderly and disabled.

5.77 Dealing with these building blocks in turn, the report says that every significant centre of population should have an Acute Medicine and Accident Centre as well as a triage area for immediate assessment as to whether patients need to be directed to their GP at a Community Hub, to the Urgent Care Centre for immediate treatment and discharge, or to the attached Accident and Emergency Department with supporting Acute Surgery for urgent intervention and probable admission to the hospital for further treatment. It argues that it is essential that the Urgent Care Centre and Accident and Emergency centre are based at the same premises.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.78 It also raises the prospect of a limited Accident and Emergency service that can stabilise patients effectively, with IT links to consultant/specialist back-up from a linked major Accident and Emergency unit – and adds that this would be appropriate as part of a Community Hub in outlying districts like Tregaron and Ammanford.

5.79 The report discusses what it sees as the necessary range of ambulance and other patient transport services to be provided seven days a week, 52 weeks a year. Where patients are discharged after 10.30pm and before 8.30 am, it believes it should be the hospital’s responsibility to ensure they have suitable transport to their place of residence.

5.80 The report’s discussion of clinical centres of excellence is very brief. It simply says they should be located where they will be most effective, easiest to access and attract the necessary funding through body mass. It then says only that each hospital should have an Acute Beds section for patients recovering from surgery and for observation; and that elective planned surgery needs to be distributed across the whole of the Health Board with specialist areas in particular hospitals.

5.81 Regarding convalescence/rehabilitation units, the report wants to learn from current initiatives, but says that at each hospital there should be separate buildings for long-term non-acute care, respite care, routine phlebotomy, podiatry, physiotherapy, dental care, ophthalmic services and for convalescence, where people from all age groups can convalesce and be rehabilitated where necessary. Social care services should also be based at the rehabilitation units and be used to monitor the overall health of the County’s population.

5.82 The report says that respite and support for carers, the vulnerable and the disabled should be run by County Councils – with care packages to ensure that as many as possible can live at home.

5.83 The report argues that community hubs involving all relevant agencies should be supported by GPs from their surgeries and using District Nurses where appropriate. The hubs should be largely based at existing sites, possibly those operated by the Local Authorities as Residential Homes, Day Centres or Sheltered Accommodation, or by expanding GP Surgeries. The report believes that residential care in both the private and public sectors should be expanded to take into account the year-on-year increase in the elderly population.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.84 Following the main report, there are eight appendices, two of which are ‘historical’ reports of past decisions, as follows:

Appendix 1 – reviews the 2003 Accident and Emergency closure at Prince Philip Appendix 2 – reviews the 2007 Accident and Emergency closure at Prince Philip Appendix 3 and 3a-3d – various comments on Prince Philip and its Accident and Emergency services and profiles of Hywel Dda Appendix 4 – an article on “Travel Times and Mortality” that concludes: Decisions regarding reconfiguration of acute services are complex, and require consideration of many conflicting factors. Our data suggest that any changes that increase journey distances to hospital for all emergency patients may lead to an increase in mortality for a small number of patients with life-threatening medical emergencies, unless care is improved as a result of the reorganisation. However, even then it is not certain that it would be acceptable to trade an increased risk for some groups of patients, such as those with severe respiratory compromise, for a reduced risk in other groups such as those with myocardial infarction. Appendix 5 – ambulance data for Hywel Dda Appendix 6 – Hywel Dda demographic profiles Appendix 7 – emails and letters of complaint or protest about current plans Appendix 8 – critique of Urgent Care Centres.

Town and Community Council submissions

5.85 Submissions were received from 61 Town and Community Councils representing Carmarthenshire, Ceredigion, Gwynedd, Pembrokeshire and Powys.

5.86 Most of the submissions and letters of protest have been overwhelmingly concerned with “keeping their local District General Hospitals” on the basis of distance, travel times, ease of access for patients and their families and the cost of the listening and engagement process and the forthcoming consultation. Some of the key themes and arguments relate to a specific hospital and geographical area, therefore, the key themes and arguments have been reported separately by county. Ceredigion, Powys and Gwynedd are reported together because they reference Bronglais and similar key themes emerged:

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Ceredigion, Gwynedd and Powys

Ceredigion Key Themes and Arguments

Town Councils Access to Accident and Emergency Services Cardigan Longer journeys and transfer will result in unnecessary and Lampeter unacceptable loss of life Community Councils

Beulah Blaenrheidol Access to planned care Borth Increasing journey times further would create much stress and Bro Cliau Aeron upheaval for patients Ceulanameasmawr The growing elderly population will be hardest hit by travelling Genau'r Glyn greater distances Llandyssiliogogo Increasing travel time will have financial implications for Llangoedmor patients and visiting families Llangybi Llanilar Longer journeys and arranging transport adds anxiety and Llanrhystud stress for patients and visiting relatives Llansantffraed Increasing distances to travel in rural areas is problematic due Llanwenog to lack of public transport links and infrastructure Llanwnnen Ceredigion is in an unique location - away from major Melindwr transport hubs e.g. South Wales M4 corridor and North Wales Nantcwnlle A55 Troedyraur Ystrad Fflur Ystrad Meurig The future of Bronglais District General Hospital Bronglais should provide a key role in the provision of health Powys services for Ceredigion and Mid Wales Proposals to cut services do not reflect the size of the Town Councils population Llanwrtyd Aberystwyth is the strategic centre in mid-Wales – therefore it Machynlleth needs to have a major hospital service Rhayader Bronglais should retain all major, emergency and maternity Community Councils services Caersws Hospital services should be improved – not reduced Carno Glantwymyn Location shouldn’t affect quality of care – provision should be Llanafanfawr and Llanwrthwl consistent in the North and South of the health board region Llanbrynmair Llandinam Listening and engagement process St Harmon The listening and engagement process has led to confusion Y Banwy about the future of Bronglais Gwynedd Further detailed information needs to be available to the public – for instance how far will patients have to travel? Town Councils Gwynedd The listening and engagement process has lacked of clarity and Dolgellau transparency Tywyn Concern about the overall cost of the listening and Community Councils engagement process Aberdyfi Arthog Brithdir, Llanfachreth and Rhydymain Corris Llangelynnin Llanuwchlyn Pennal

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Pembrokeshire

Pembrokeshire Key Themes and Arguments

Town Councils Closure of Tenby Minor Injuries Unit Haverfordwest Opposition to the closure of the Minor Injuries Unit at Tenby Milford Haven in 2012 (without public consultation) – closed in order to keep Pembroke Withybush Accident and Emergency Unit open Pembroke Dock Community Councils The area needs a Minor Injuries Unit - particularly in the Summer months for holiday makers and elderly population Jeffreyston Kilgetty Begelly Penally Future of Withybush District General Hospital St Mary Out Liberty Opposition to the continued reduction of services at Saundersfoot Withybush

Listening and Engagement Process Lack of information has led to anxiety about the future

Carmarthenshire

Carmarthenshire Key Themes and Arguments

Town Councils Future of Prince Philip District General Hospital Llanelli Location of health services should reflect population size Pembrey and Bury Port It is a rural solution for an urban area Tenby Wards of multiple deprivation – should not make vulnerable Community Councils groups of people travel great distances to receive care Llanedi Prince Philip should be restored to a fully functioning District Llannon General Hospital Llanelli Rural Council

Listening and Engagement Process No confidence in proposals No use of patient-based data and the impact of distance to travel to support proposed options

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Voluntary, community group and other organisation submissions

5.87 Submissions were received from 64 voluntary, community group and other organisations across Carmarthenshire, Ceredigion, Gwynedd, Pembrokeshire and Powys. The list of contributors, separated by county, are shown below.

Carmarthenshire Ceredigion Pembrokeshire

Bipolar UK Aberporth Merched y Wawr Communities First Canolfan Plant Sir Gar Aberystwyth guild of students Tenby Junior Community School Cellan Women's Institute Board at Neuadd Pantycelyn Pembroke Dock Civic Society Llanelli Disabled Drivers Association Ceredigion Age Cymru Mental Health Learning Disabilities Crohn's and Colitis UK stakeholders Fforwm Strata Florida 50+ forum Retired Friends United Ger Y Gors Community Forum Safer Communities Action Group Merched y Wawr Aberystwyth Merched y Wawr Y Dderi Sarn Helen 50+ Forum Un Llais Cymru /One Voice Wales Ceredigion Women’s Institute Powys Organisations Aberaeron WI Salop Leisure Abermeurig WI Caersws Friendship Hour Club Aberporth WI Clwb Maglona - Bro Ddyfi Senior Citizens Bwllchllan WI Machynlleth Patients Forum Caerwedros WI The league of friends of Machynlleth Cellan WI Hospital and Cartref Dyfi Ceredigion Federation of WI Eglwysfach WI Powys Cross Inn WI Dihewyd WI Lampeter WI Gwynedd Llanddewi Brefi WI Llanafan WI Aberdovey WI Llanon WI Llanwnnen WI Penllwyn WI Penrhyncoch WI Pontrhydfendigaid WI Rhydypennau WI Taliesin WI Waunfawr WI

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

5.88 The following key themes and arguments emerged from voluntary, community groups and other organisations’ submissions:

Key Themes and Arguments Key Themes and Arguments

Access to planned care Centres of Excellence Centralising services will increase travel distance and time and Specialists at Bronglais provide an essential service for the will affect patients, families, student and tourist populations - local area there is no justification for increasing travel times any further Prince Philip covers a large area – the possibility of the closure Increased travel will place a strain on ambulance provision of the Accident and Emergency is appalling Increased travel will have financial implications for patients Centralisation does not take into account the current and visiting families population size and future growth Longer journeys and arranging transport adds anxiety and Concern over the loss of services at each of the four hospitals stress for patients and visiting relatives (colorectal surgery, maxillofacial clinics and maternity services) Public transport links are poor Quality services should be expanded and not reduced The condition of the roads are poor and are susceptible to unfavourable weather conditions (flooding) Rural areas will be particularly affected by increasing distances to travel Access to Accident and Emergency Services Opposition to the lack of concern regarding the ‘golden hour’– ambulances are not mobile hospitals The necessary journey time for seriously ill people would be far beyond the ‘golden hour’

Listening and engagement process (particularly in Elderly patients relation to Your health, Your future literature) Senior citizens will find it difficult to travel – downgrading is a Sceptical over the extent the public can influence the listening way of undermining the security and well-being of the elderly and engagement process – HDdHB hasn’t acted upon concerns Increased travel time will cause pain and discomfort – voiced by the public especially for the elderly population The ‘numbers’ used within the literature do not add up – Ageing population needs more not fewer services HDdHB does not have access to patient numbers in its system A full consultation is required before decisions are made

Recruitment and staffing Care closer to home Current staffing issues have been caused by lack of More care to be provided locally through better access to recruitment and advertisements primary care – positive if proposals lead to more services being delivered locally Provide support for junior staff training and consultants for Care closer to home does not make sense if you have to travel key departments a three hour journey to the nearest hospital

Health needs Tenby Minor Injuries Unit Glanymor and Tyisha wards have some of the greatest health Concern about the effect on schools who frequently use this needs in Wales but the poorest access to NHS services service

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Residents’ submissions

5.89 388 submissions were received from residents across the following areas: » Ceredigion – 109 submissions » Carmarthenshire – 59 submissions » Gwynedd – 53 submissions » Powys – 43 submissions » Pembrokeshire – 40 submissions » Miscellaneous – 84.

5.90 The following key themes and arguments emerged for residents’ submissions:

Key Themes and Arguments Key Themes and Arguments

Access to planned care Listening and engagement process Travel time is inconvenient for all population groups Concern about the cost of the listening and engagement Longer journeys will have an impact on visiting friends and process– in particular the DVD which did not work family Further information is required on proposals and the evidence Population increases in the summer months will cause delays for change – the ‘Your Health, Your Future’ literature to journey times The literature provided lacked substance and has been Extra community ambulances will be needed in mid Wales to inconsistent cope with the extra travel and journeys required No mention of Gwynedd, Powys or Montgomeryshire – even Inadequate roads - the roads in Aberystwyth are some of the though these areas account for a third of the patients for most dangerous in the UK Bronglais In rural areas public transport is poor The proposals have ignored the large numbers of patients treated by Bronglais surgeons HDdHB has failed to engage with local people about the health needs of the region The questionnaire used was ‘loaded’ compromising the validity of the listening and engagement Process No reference to dentistry services More information needed about non-emergency hospital transport

Access to Accident and Emergency Services Listening and engagement process (particularly in relation to Concentrating hospital provision in the South will put lives at the drop-in sessions) risk in the North – the ‘golden hour’ will be compromised Weekday drop-in sessions discriminated against people in Lives will be lost travelling the extra miles employment Time spent in an ambulance will increase - ambulance staff Lack of engagement with residents by Hywel Dda – no are not trained to deal with critical treatments representative of Hywel Dda present at some meetings Longer journeys will place a strain on ambulance provision Discussion documents contradicted information given at Decision to downgrade the only Accident and Emergency in meetings mid Wales in an area where accidents occur regularly - rural Event at Selwyn Samuel Centre – rudeness, failed to answer tourist, farming and student questions Flooding and extreme weather conditions can lead to lengthy Larger meeting venues and more meetings required travel detours

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key Themes and Arguments Key Themes and Arguments

Care closer to home Centres of Excellence Care at a local hospital is key to patients’ recovery People should be entitled to equal access/standard of Need effective care in the community treatment across Wales – care should not be restricted to the Care would be beneficial at home M4 corridor Economical to divide the consultants’ commitments rather than forcing elderly and ill patients to travel Acute care should be provided locally It makes sense to have specialist centres – it is not feasible to have a specialist available 24 hours a days in smaller hospitals

Elderly patients Rural areas Concern that the elderly population will be most affected by Reorganisation does not take into account rural isolation increased distance to travel Many hospitals in South and North Wales – only one in mid Elderly population requires more medical services and Wales interventions Urban solution in a rural area – care should be the same Care for elderly patients should be kept as local as possible as regardless of where you live transport difficulties will be greater (reliance on public transport and families)

Recruitment and staffing Hywel Dda Health Board Current recruitment problems could be as a result of morale Support for HDdHB to be disbanded issues in each of the hospitals HDdHB should not exist Incentives are needed to attract staff to the area Want the truth from HDdHB rather than political spin Don’t waste money on senior staff pay HDdHB is poor at public relations Re-instate matrons and recruit administrative staff, cleaners and maintenance staff Better qualified medical staff and more efficient working conditions would help towards saving money Recent changes to HDdHB and perceived poor management has discouraged doctors, consultants and nurses wanting to work in the localities

The future of Bronglais District General Hospital The future of Prince Philip District General Hospital Bronglais hospital is a vital local service Concern about downgrading Prince Philip – alternative Upgrade not downgrade hospitals at full capacity A third of Wales relies on Bronglais A town the size of Llanelli needs a fully functional Accident and The plans are unfair and damaging to people who rely on Emergency Unit – Llanelli is a better option as opposed to Bronglais Carmarthen based on population size and services already available at the hospital Any attempt to remove services at Bronglais is callous and dishonest Can understand why alterations are being made to Prince Bronglais is the only hospital of decent size in mid Wales Philip because of its proximity to Morriston hospital (Swansea) Prince Philip is relied upon too much by patients – it is not cost effective

The future of Withybush District General Hospital The future of Glangwili District General Hospital Withybush in crisis Care should not be centralised at Glangwili Concerns over recent job losses Distance already too far to travel when you have a serious Tenby Minor Injuries to reopen to decrease the strain on illness such as a stroke Withybush Glangwili is very close to other services in South Wales Services should be restored and core services should be (Morriston and Singleton) retained in Withybush – in danger of becoming a cottage Aberystwyth, Haverfordwest and Llanelli should be upgraded hospital and Carmarthen downgraded One of the four hospitals – preferably Withybush should become a teaching hospital

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key Themes and Arguments Key Themes and Arguments

Women and children’s services Safety Not acceptable for a baby to be separated from its mother and Financial constraints are irrelevant when it comes to safety taken to a different hospital Feel unsafe in the care of HDdHB Concern about the implications for women in labour – proposals are putting women and babies lives in danger

Staff and GP submissions

5.91 26 submissions were received from staff and GPs across Hywel Dda and Gwynedd: » Ceredigion – 9 submissions » Carmarthenshire – 3 submissions » All Hywel Dda – 4 submissions » Gwynedd – 4 submissions » Pembrokeshire – 2 submissions » Miscellaneous – 4 submissions.

5.92 The following key themes and arguments emerged from staff and GP submissions:

Key Themes and Arguments Key Themes and Arguments

Access Accident and Emergency Services Centres of Excellence Distance and journey times will increase patient risk Hospital services should be expanded – not reduced Acute admissions within the ‘golden hour’ will be To downgrade Bronglais would be detrimental on patient compromised groups (pregnant mothers, the mentally ill etc.). Dangerous to rely on the availability of ambulance/helicopter The plans fail to take into account healthcare needs for urgent transfer

Listening and Engagement Process Women and children’s service HDdHB has managed the process poorly and it has not been To have one maternity service is a safety risk – there should be clinically-led (as previously stated) an Obstetric Unit alongside a midwifery unit Decisions have already been made by HDdHB Converting Withybush into a stand-alone midwifery led unit Powys residents are concerned they have been forgotten will cause safety issues Increased distance to travel would be a greater risk to pregnant mothers

Care closer to home Support for change Disagree with the scenario that GP’s take responsibility for The NHS must change pre-assessment and post-operative care A community focussed model is welcomed

Need to develop further community specialist services Hospitalisation needs to reduce

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

6. Petitions Expressions of Concern

Introduction

6.1 There has been considerable interest and in many cases disquiet arising from people’s fears about the potential implications of HDdHB’s review of clinical services – which has been expressed in the form of petitions to the Health Board. Obviously, petitions must be given their due weight in that they reflect wide-ranging concerns, but their significance can be difficult to interpret: for they can be spontaneous expressions of concern based on a sound understanding and consideration of the issues; or they can comprise relatively casual and/or uninformed signatures based upon emotive statement by motivated organisers.

6.2 In order to publicise the petitions and make their content and significance more accessible to the Board, we have summarised the main ones below. Briefly, there were ten main petitions: Re Prince Philip Hospital: Welsh Government on-line e-Petition Petitions organised by Sosppan e-Petition backed by Llanelli town and rural councils, the Committee for the Improvement of Hospital Services and the Llanelli Star. Re Bronglais Hospital: Petition organised by the Cambrian News Petition organised by Cadw'n Lleol–Ysbyty Bronglais Petition organised by Members of Caersws Friendship Hour Club Petition organised by unknown others Re Temporary Closure of Minor Injuries Units: Petition organised by unknown others regarding Tenby Hospital Petition organised by unknown others regarding Tenby and South Pembrokeshire Hospitals 48 pre-completed questionnaires submitted to ORS.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Petitions about Prince Philip Hospital

6.3 The on-line petition submitted via the Welsh Government’s website has been running since 29th December, 2011, and has so far attracted 984 valid signatures. The petition statement declares: Hywel Dda Health Board is planning to downgrade or close A&E services at Prince Philip Hospital. This is an essential service for Llanelli and the surrounding communities and the community needs to act to save our A&E. Please sign this Petition to prevent the closure of this essential service, and to ensure lives are not put at risk.

6.4 Further petitions against changes to Prince Philip Hospital were mainly organised by the long-running special interest group called Committee for Hospital Improvement / Sosppan (Save Our Services Prince Philip Action Network). An initial petition attracted about 9,000 signatures and a later petition attracted over 26,000 signatures and was presented to Welsh Government’s Petitions Committee on 23rd May 2012. The campaigning poster for the demonstration at the Senedd is shown below.

6.5 One version of the petition statement declared: Hywel Dda Health Board is planning to downgrade or close A&E services at Prince Philip Hospital. This is an essential service for Llanelli and the surrounding communities and the community needs to act to save our A&E. Please sign this Petition to prevent the closure of this essential service, and to ensure lives are not put at risk.

Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

6.6 A further version of the statement, which appeared in the Llanelli Star newspaper, said: We, the people of Llanelli, the town with the largest population within the Hywel Dda area demand Prince Philip Hospital be restored to a fully functioning District General Hospital with the return of major elective surgery, including gastrointestinal, vascular, urology, gynaecology and trauma, with support from the original five ITU beds fully staffed, which would support a fully staffed, consultant-led Accident and Emergency Department, providing support for physicians.

6.7 Another e-Petition (deriving from the Llanelli Start text above) with 282 signatures was submitted to Hywel Dda Health Board and the Welsh Government on 9th March 2012, backed by Llanelli Town and Llanelli Rural councils, the Committee for the Improvement of Hospital Services / Sosppan and the Llanelli Star. The petition statement declared: Give Llanelli a fully functioning district general hospital. Greetings, I just signed the following petition addressed to: Hywel Dda health board and the Welsh Government. Give Llanelli a fully functioning district general hospital. We, the people of Llanelli, the town with the largest population within the Hywel Dda health board area, demand Prince Philip Hospital be restored to a fully functioning district general hospital with the return of major elective surgery, including gastrointestinal, vascular, urology, gynaecology and trauma, with support from the original five ITU beds fully staffed, which would support a fully staffed, consultant led accident and emergency department, providing support for the physicians.

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Petitions about Bronglais Hospital

6.8 A petition organised by the Cambrian News (with advice from local interest groups) attracted 8,067) signatures and was presented to the Lesley Griffiths, the Minister for Health on February 29th 2012. The petition statement declared that: I, the undersigned, call on Hywel Dda Health Board and the Welsh Government to maintain Bronglais Hospital’s standing as a District General Hospital and to keep all major and emergency surgery at Aberystwyth.

6.9 The covering letter accompanying the petition to the Welsh Government is reproduced below: To Minister for Health, Welsh Government - 29 February 2012 Please accept from the Cambrian News, on behalf of its readers, a petition signed by a massive 8,087 local all people concerned about the moves to centralise services away from Bronglais Hospital. These signatories live in Ceredigion, Powys and Gwynedd, in the huge geographical area served by Bronglais Hospital. Hywel Dda Health Board's plans fill residents with fear over the safety of patients, as the proposals would mean travelling of well above the "golden hour" for treatment. In fact there could be emergency journeys of well over two hours for some seriously ill people, something which we are sure you will agree is totally unacceptable. Also we urge you to take account of the huge burden centralisation puts on family and friends of hospital patients taken up to 80 miles away from home. If you view the map showing the location of our district general hospitals you will see that mid Wales has just one hospital and the M5 corridor has 12. This surely shows the unique situation at Bronglais and adds weight to the case for services there to be strengthened not diminished. A separate health plan for mid Wales is needed. Please take into account the views of Bronglais’s own consultants, the majority of whom, as you know, have signed a letter saying they have lost all confidence in Hywel Dda Health Board. They are joined by retired medical experts on the aBer Group and the majority of local residents in urging that the current proposals be abandoned.

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Our petition comes in three different formats. There are campaign coupons cut out from the Cambrian News, there are hard-copy petition forms, and there are petition forms filled in on-line (the latter have been saved onto a CD). As the originals of our petition are being handed to your department, l would be grateful if you could make it available to Hywel Dda Health Board. The worried people of mid and west Wales are relying on you to protect their interests and the future of their hospital. Beverly Thomas, Managing Editor, Cambrian News Ltd.

6.10 A further Welsh language petition about Bronglais, under the banner, Cadw’n Lleol, attracted 5,306 signatures with a petition statement that read (in translation): Keep it Local We, the undersigned, call on Hywel Dda Health Board and the Welsh Government to keep Bronglais Hospital as a District General Hospital. Also, to keep all main surgical and emergency services as they are and to serve Aberystwyth and the surrounding area. The Health Care for our people must be kept locally.

6.11 A third smaller petition, organised by Members of Caersws Friendship hours Club, attracted 373 signatures for a petition statement that declared: We, the under-signed call on you, Minister, to assure us that services at Bronglais Hospital will remain at their current levels, and all major emergency, elective and obstetric services will be kept at Bronglais Hospital, Aberystwyth.

6.12 Finally, another e-Petition opened on the April 4th and attracted 3,804 signatures opened on 4th April 2011. The petition statement says: BRONGLAIS HOSPITAL PETITION/DEISEB YSBYTY BRONGLAIS

We, the undersigned, call upon the Hywel Dda Health Board to review and alter their plans for all services at Bronglais District General Hospital.

Adults and children of Mid Wales deserve excellent health care services. Bronglais Hospital is the key to delivering accessible services to this population.

Whilst welcoming the Minister’s recent statement concerning the allocation of £38 million to Bronglais, we would urge that such a development, welcome though it is, must always be seen against the disinvestment in Bronglais over the last few years.

We need immediate action to stop the erosion of services in Mid Wales.

We need increased bed numbers and three new operating theatres meeting modern standards to be built to support local access to safe emergency and elective surgical, trauma, orthopaedics

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Petitions about the Temporary Closure of Minor Injuries Units

Tenby Cottage Hospital

6.13 The petition attracted 2,160 signatures. The Petition statement declared:

To Mr Chris Martin and Mr Trevor Purt, Chairman and Chief Executive of Hywel Dda Local Health Board.

We the undersigned are deeply concerned at the decision taken by your organisation to close the Minor Injuries Unit in Tenby Cottage Hospital on 3rd January 2012 and we ask that you urgently rescind this decision and maintain its normal hours of opening for the benefit of this town and the surrounding community of South Pembrokeshire.

Petition to Keep the Minor Injuries Units at South Pembrokeshire and Tenby Open

6.14 The petition attracted 2,551 signatures. The petition statement declared:

Hywel Dda (the health board) have decided to close the Minor Injuries Units at both South Pembs and Tenby, this petition is to show the local residents’ disappointment at the removal of these important local medical services, and to request that they are left in operation to give local people easy access to medical care.

Pre-completed Questionnaires

6.15 It was inappropriate to include 48 printed questionnaires in the main analysis of returns because they were identical and pre-printed for respondents to submit – so in this sense, they were not completed by individuals. However, because they all showed strong disagreement with HDdHB on all the key issues, their significance should be recognised – and we have concluded that they are most appropriately considered as forming a petition.

6.16 The 48 questionnaires were all pre-completed to show strong disagreement with all the questions in the HDdHB listening and engagement questionnaire; and they also included standardised, pre-printed comments to all the questions. Condensing the comments into a single ‘narrative’ yields the following composite text: I agree that we should provide care more locally, but I am unable to agree with the 80% claimed because the Health Board has given no information on how much this will cost and where the resources to deliver this will come from. Furthermore the Health Board has not defined what it means by local. I agree that quality and safety of services is important but I cannot agree that the standards selected are appropriate to the needs of a rural health service. I agree that the ageing population will be a service priority, but the Health Board needs to invest in health promotion and prevention. However the Health Board cannot withdraw resources from acute services to deliver new health management services to such an extent that the population will be penalised by not getting appropriate and timely treatment in an emergency (Golden Hour).

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I cannot agree with specialising some services into fewer, fully equipped centres because insufficient evidence has been presented. I am not clear what services need to be centralised and more importantly what the 'knock on' effect on other services would be. I need to know who is providing this advice so I can see if they have a fair and balanced view. I also want to know which professionals are providing the advice, and see any conflicting evidence before being able to assess the credibility of the statement. Specialised services can be provided as part of a network. Doctors can travel and are often more able to travel than patients who are ill and vulnerable. The health board must remember the important support given to patients by friends and relatives visiting. The Health Board will have to ensure that patients who have to travel to centralised services are reimbursed their costs e.g. travel, child care and lost income. It is unfair to expect patients to pay for problems which the Health Board has created. People can travel North as well as South to access services. I agree that services should not be duplicated. I expect the Health Board to arrange services across Mid and South West Wales so that all residents have access to equitable treatment. There is far more duplication along the M4 corridor, whereas there is only one DGH for the Mid Wales region. To meet the requirements of best treatment (Golden Hour) there is scope for rationalisation where hospitals are geographically close, but not where there is only one covering a large area. Insufficient information has been provided. The Health Board has told us all the things it purports it can’t do, whereas many management boards across the world have found safe effective solutions to provide acute care to rural populations. Whoever manages Health Services in Mid Wales needs a positive, creative and equitable approach. The whole approach of the Health Board is negative and unimaginative; but mostly it is simple morally and ethically wrong to penalise the population of Mid Wales. Finally this questionnaire is structured to try to provide answers that support the Health Board’s centralising agenda and as such has been hard to complete in any sensible way.

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The Need for Interpretation

6.17 The petitions summarised above are clearly important in indicating the scale of public anxiety in Llanelli, Bronglais, Tenby and South Pembrokeshire about important aspects of the clinical services review and the future of the minor injuries units at South Pembrokeshire and Tenby – and the authority will wish to treat them very seriously. Nonetheless, the HDdHB should also consider that petitions can exaggerate general public sentiments if they are organised by highly motivated opponents. In most of these cases, the petitions resulted from well organised local campaigns backed actively by influential newspapers and groups. Certainly, the petitions and other submissions should not be disregarded, for they show a considerable intensity of feeling and indicate the grounds for public opposition; but they should be interpreted in context.

6.18 For example, the petitions are all very local in their focus. There is evidence that many of the people signing the Prince Philip petitions will have based some of their views on the false premise that the hospital currently provides a full Accident and Emergency service. The Welsh Government e-Petition statement says that HDdHB is planning to downgrade or close the Accident and Emergency services and adds the emotive appeal that people should sign to ensure lives are not put at risk. The Llanelli Star petition statement could be described as a call for loyalty to the town; and it does not correct the popular assumption that Llanelli currently has a full Accident and Emergency service. The Bronglais petitions are fundamentally a call for all major medical and emergency services to be provided locally and a protest about the erosion of important services. The Tenby and South Pembrokeshire petitions reflect understandable local concerns about the loss of facilities. This interpretive perspective certainly does not discredit the petitions, but provides a context within which they should be interpreted.

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7. Schedule of Listening and Engagement Activities Introduction

7.1 The schedule of activities for the listening and engagement process covered a wide range of methods and events across the areas covered by the Hywel Dda Health Board during the period from December 2011 to April 2012. These activities included public drop-in events, staff engagement events (road- shows, focus groups, on-line questionnaires, forums, articles in the ‘Voice’ staff newsletter), information sharing with key stakeholders (including medical professionals via email and post) discussions and presentation at Community Health Councils, Open Hywel Dda Board meetings and forums. In addition, briefings and presentations were also provided to local Assembly Members, Members of Parliament and special interest groups, including Save Withybush Action Team (SWAT), Save Bronglais Hospital Campaign and Save Our Services Prince Philip Hospital Campaign (SOSPPAN).

Meet the Health Board Sessions and Public Forums

7.2 HDdHB arranged and facilitated 12 Meet the Health Board drop-in sessions and forums with members of the public. These varied in format but essentially gave interested residents the opportunity to ask questions and voice their views about the case for change. The sessions were widely publicised by HDdHB and were well attended. HDdHB facilitated 10 meetings in each of the seven HDdHB localities and two additional groups in Powys:

February 2012 Cardigan (1st February 2012) - 71 attended Carmarthen (3rd February 2012) - 46 attended Newport (9th February 2012) - 62 attended Llanelli (14th February 2012) - 549 attended Llandybie (16th February 2012) -30 attended Aberystwyth (22nd February 2012) -225 attended

March 2012 Machynlleth – Powys (5th March 2012) - 128 attended Llanidloes – Powys (5th March 2012) - 59 attended

April 2012 Carmarthen ( 19th April 2012) -28 attended Lampeter (24th April 2012) - 25 attended

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Llandovery (26th April 2012) - 16 attended Saundersfoot (26th April 2012) - 30 attended (approximately).

7.3 Because of their importance, we have briefly summarised the main themes and outcomes (from records kept by HDdHB) below.

General Themes and Arguments

7.4 Despite many concerns, there was some considerable support for the general case for change in some meetings, primarily on the grounds that: resourcing four District General Hospitals is unsustainable; centres of excellence will improve patient outcomes; and care in the community is favoured. That said, the public forums held in Llanelli and Aberystwyth were overwhelming against the HDdHB case for change. Therefore, these groups are reported separately below.

7.5 Despite concerns relating to distance to travel and the impact on patients and visiting families, HDdHB’s notes show that the principle of centres of excellence was generally supported.

7.6 Care closer to home was also generally welcomed on the premise that further services will be accessible in the community, some of the main concerns were that: GP ‘out of hours’ services are not provided GPs workloads are currently overstretched – how can they do anymore? Services are not ‘joined-up’ Some services are not available in the Hywel Dda area – Telecare Acute Response Extended GP Services.

7.7 The following recommendations were made: 24 hour community care should be available Increase the volume of staff working in the community A greater community role for the District Nurse.

7.8 Emergency services were regarded as essential and therefore reassurance was needed that if emergency surgery is required it would be received at the nearest hospital.

7.9 Some specific issues concerning women and children and mental health were raised Women and children – Stand-alone midwifery led units are unsafe Mental health - More services required in the north.

7.10 In some of the events, local issues of concern were raised: Cardigan – uncertainty over the future of Cardigan hospital Carmarthen – lack of mental health services Llandybie – patients have to travel to Ammanford since the closure of the GP surgery – calls for the reinstatement of the surgery.

7.11 Although the listening and engagement process was welcomed, there were some criticisms: Advertisement – lack of event publicity

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Venues – limited space and parking Time - discriminated against employed people - weekend events preferred.

Llanelli

7.12 This following summary cannot do justice to the acute sense of disapproval and anxiety about the impending clinical services review that was evident in all three of the Llanelli sessions during the listening and engagement event.

7.13 The Llanelli attendees felt that little effort to improve clinical recruitment has been made by HDdHB. In fact, they felt that the prospects for clinical recruitment would improve if a fully functioning Accident and Emergency service existed at Prince Philip.

7.14 While critical of the principle, in general, they supported making Prince Philip a centre of excellence. The care provided at the Breast Care Centre was praised.

7.15 There were concerns that HDdHB has a rural plan for an urban area. Attendees were of the opinion that Llanelli should be treated differently to the rest of Hywel Dda. They favoured ‘upgrading’ the emergency services currently offered at Prince Philip and were aggrieved that, considering the large patient population, they could be left without a fully functioning Accident and Emergency Unit. Also, Glangwili is already overstretched and deemed unable to deal with further patients who would otherwise attend Prince Philip.

7.16 Ambulance provision was a particular concern and it was suggested that the service is already overstretched leading to long waiting times. It was considered that extra ambulance provision would be required and this would lead to a cost that was not accounted for in the literature.

7.17 The idea of care in the community was regarded with scepticism, due to the recent loss of community health facilities in the area.

7.18 Above all, increases in distances to travel was judged to be wholly unacceptable. It was thought that this would have the greatest impact on the elderly and would have financial implications for all patients and visiting relatives.

7.19 The attendees were highly critical of the listening and engagement process and principally their particular event. Their main criticisms were that: Audibility – lack of microphones/public address system Agenda – timekeeping not adhered to – people had to leave Advertisement – lack of event publicity Question and answer sessions – audience interruptions and panel not answering questions Venues – limited space and overcrowding.

Aberystwyth

7.20 As in Llanelli, there was considerable anger and disillusion shown towards the Board at the meeting.

7.21 The Aberystwyth attendees felt little was known concerning the extent to which HDdHB had considered plans for Bronglais in conjunction with Betsi Cadwaladr and Powys Health Boards.

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7.22 The idea of care in the community was welcomed, but affordability and sustainability was perceived to be barriers. There was also concern that greater strain would be placed on carers.

7.23 Increased distance to travel was a major concern. It was thought that this would have the greatest impact on the elderly and those without access to transport and would have financial implications for all patients and visiting relatives.

7.24 The Aberystwyth attendees felt that recruitment has been negatively affected due to low levels of staff morale at Bronglais. In fact, they felt that much could be done to make it more attractive for potential recruits.

Machynlleth and Llanidloes

7.25 In addition to the meetings held within the three counties, two listening events were facilitated by Powys Health Board and were held in Machynlleth and Llanidloes. The events were organised following media and community responses to engagement materials published by HDdHB and the specific concerns at the implications for changes to services delivered at the Bronglais hospital in Aberystwyth.

7.26 Their main concerns and arguments were: Services at Bronglais should be maintained and extended to serve mid Wales particularly given its geographic isolation from other large general hospitals Travel and transportation distances for patients and visitors will increase HDdHB had not planned listening events outside of their organisational boundary – and had not taken into account the effect on Powys residents Service reductions would affect the local economy and discourage people moving into the area In order to reduce travel and improve access Powys should offer more services locally including: Minor Injury; improved GP out of hours; twilight district nurses; and community hospitals.

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Complete Schedule of Key meetings

7.27 The following information outlines the extent of communication and engagement activity that has taken place during key meetings during the listening and engagement phase from December 2011 to the end of April 2012. Key meetings Date Time Venue Lead (if relevant) Number of attendees 3rd January Briefing Event for Managers Chair/CEO 50 + 5th January North Powys Locality Meeting Not recorded 6th January Ceredigion Local CHC Meeting approx 12 9th January Staff Road-show, Hafan Derwen 1 Independent 40+ Member 4 Executive Directors (inc 1 clinical director) 9th January Therapies & Health Sciences Formal Forum 9th January Winch Lane –Meeting with Angela Burns 2 and Paul Davies 10th January Machynlleth Patients Forum 33 11th January Staff Road-show, Withybush 5 Executive 120 + Directors (inc 2 clinical directors) 3 County Management Team (inc 1 senior clinician) 11th January Medical Staff Committee 11th January 10.00am Third Sector Three Counties 38 Listening Event, Bloomfield Hall, Narberth 11th January 7.00pm Pembrokeshire GPs Think Tank, 15 Pembroke Dock 12th January Staff Road-show, Bronglais 5 Executive Directors 110+ (inc 1 clinical director) 5 County Management Team (inc 3 senior clinicians) 12th January Pembrokeshire Local CHC Committee approx 12 13th January Staff Road-show, Glangwili 4 Executive Directors 80+ (inc 1 clinical director) 6 County Management Team (inc 3 senior clinicians) 13th January Staff Road-show, Prince Philip 1 Independent 200+ Member 6 Executive Directors (inc 2 clinical

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Key meetings Date Time Venue Lead (if relevant) Number of attendees directors) 6 County Management Team (inc 3 senior clinicians) 14th January Pembrokeshire Collaboration of Town and Community Councils 16th January Carmarthenshire Partnership Forum 17 16th January Ceredigion LSB 13 17th January Cultural Steering Group 14 17th January Three Counties Partnership Forum, 25 Prince Philip Hospital !8th January Community Health Council Chair 2 CEO 18th January Cardigan Hospital League of Friends / 40 Cardigan Town Council Meeting 19th January 1pm - 4pm Carmarthenshire Voluntary 16 Sector HSC&WB Forum 19th January GP Forum 12 24th January Healthcare Professions Forum 10 24th January Tregaron Staff Meeting 20 25th January Meeting with Sosppans Representatives Chair 3 3 Executive Directors

1st February 11.00am - 6.00pm Meet the Health 1 Independent 71 Board Drop -in Event, The Great Hall, Member Cardigan 2 Executive Directors County Director and 4 other members of the senior county management team 3 Assistant Directors 1st February GP Clinical Think Tank - Carmarthenshire 7 GPs 2nd February 10.00 am Halliwell Centre 36 Stakeholder Reference Group / Health Professional Forum 3rd February Ceredigion Consultants Meeting @ Bronglais 3rd February 11.00am - 6.00pm - Meet the Health 1 Independent 46 Board Drop -in Event, Carmarthen Member Education Centre, Carmarthen 2 Executive Directors County director and 3 other members of the county Management Team (inc the associate medical director) 1 Assistant Director 7th February Pembrokeshire Health Social Care and 8

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Key meetings Date Time Venue Lead (if relevant) Number of attendees Wellbeing Board, County Hall, Haverfordwest 7th February Stakeholder Reference Group 14 7th February Health Board Meeting with SWAT Chair 3 3 Directors inc. medical director 7th February Therapies and Health Sciences Formal Forum 8th February Carmarthenshire County Council - 47 Members Event 9th February 7.00pm Pembrokeshire Town and 26 Community Councils Event, Withybush Conference Centre, Haverfordwest 9th February 11.30am - 6.30pm - Meet the Health 2 Independent 62 Board Drop -in Event, Newport Memorial Member Hall, Newport Chair 2 Executive Directors 5 County Management Team (inc county associate medical director) Assistant Directors x3 9th February Meeting with Mr Maxwell consultant chair 1 10th February Cardigan GPs Meeting 13th February Ceredigion Practice Managers Meeting 14th February 11.30am - 6.30pm - Meet the Health 2 Independent 549 Board Drop -in Event, Selwyn Samuel Member Centre, Llanelli 5 Executive Directors (inc 1 clinical director) County director and Hospital clinical Director 2 Assistant Directors 14th February Pembrokeshire Third Sector Health Social Care and Wellbeing Forum 16th February Ceredigion County Council - Members 32 Cllrs Event 20 public 16th February 12.00pm - 7.00pm - Meet the Health 3 Independent 30 Board Drop -in Event, Llandybie Member Memorial Hall, Llandybie 1 Executive Directors County director and 3 other members of the Management Team 2 assistant directors 17th February Ceredigion Consultants Engagement 40 17th February Staff Engagement, Prince Philip 2 Independent 20 Members 3 Executive Directors (inc 1

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Key meetings Date Time Venue Lead (if relevant) Number of attendees clinical director) 3 County Management Team 20th February 11.00am - 6.00pm - Meet the Health 1 Independent 49 Board Drop -in Event, Bridge Innovation Member Centre, Pembroke Dock 3 Executive Directors (inc 1 clinical director) 5 County Management Team (inc associate medical director) 21st February Hywel Dda Partnership Forum, Glangwili 22nd February 11.00am - 6.00pm - Meet the Health Independent 225 Board Drop -in Event, Y Morlan, Member Aberystwyth 7 Executive Directors (inc 3 clinical directors) County Director and 5 other members of the Management Team (inc 2 associate medical directors, clinical lead for women and children) 3 assistant directors

23rd February Pembrokeshire County Council - Members Event 23rd February North Powys GPs 35 24th February Staff Engagement, Bronglais 60+ 24th February 11.00am - 6.00pm - Meet the Health 2 Independent 85 Board Drop -in Event, Withybush Member Conference Centre, Haverfordwest Chair 3 Executive Directors 5 members County Management Team (inc 2 associate medical directorate) 3 assistant directors 28th February South East Pembrokshire Health Network Not recorded Meeting, New Hedges Memorial Hall, New Hedges 28th February OT Service Leads Meeting at Withybush 29th February Betsi Cadwaladr University Health Board Stakeholder Event, Porthmadog 29th February Cardigan Staff Events (x2 Sessions) 5th March Band 7 Focus Group, Withybush 6 5th March Powys Teaching Health Board - 2 executive 130 Machynlleth Engagement Event directors

5th March Powys Teaching Health Board - Llanidloes 70

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Key meetings Date Time Venue Lead (if relevant) Number of attendees Engagement Event 2 executive directors GP associate medical director Ceredigion 5th March MSK Outpatients Departments (Llanelli) 6th March Meeting with OT / Physio Outpatients and MSK Physio Teams from Withybush and South Pembs 8th March Joint Strategy Engagement Session with OTs and Physios at Bronglais 8th March Pembrokeshire Local CHC Committee approx 12 9th March Ceredigion Local CHC Committee approx 12 9th March Carmarthenshire Carers 14 12th March Band 7 Focus Group, Glangwili 4 13th March Carmarthenshire Local CHC Committee approx 12 14th March Burton Lunch Club, Burton Community 25 Hall 15th March Band 7 Focus Group, Bronglais 9 15th March Band 8+ Focus Group, Bronglais 7 19th March, Pembrokeshire Town and Community 26 Councils Event, Withybush Conference Centre, Haverfordwest 19th March Heads of Department Meeting @ Bronglais 21st March Aberystwyth Focus Group 12 21st March Ammanford Focus Group 9 22nd March Band 7 Focus Group, Prince Philip 7 Hospital 22nd March Ceredigion Town and Community Council 45 Event, Llwyncelyn Memorial Hall 22nd March Llanelli Focus Group 7 22nd March Lampeter Focus Group 11 23rd March Planning Meeting with BCUHB / PTHB 26th March, Carmarthenshire Town and Community 25 Council Event, St Peters Civic Hall 26th March Meeting with Angel Burns, Paul Davies 2 27th March Fishguard Focus Group 13 28th March Llandeilo Focus Group 11 28th March Milford Haven Focus Group 13 30th March Mental Health Clinical Services Strategy Workshop Event, Halliwell, Carmarthen 30th March Meeting with ABER Chair 1 +others 2 Executive directors inc medical director County director

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Key meetings Date Time Venue Lead (if relevant) Number of attendees 30th March Meeting with Elin Jones chair 1 11th April 2.00pm - 8.00pm Meet the Health Board 2 Independent 16 Event, Rhys Pritchard Memorial Hall, Member Llandovery 4 Executive Directors County director and 3 other members of the Management Team 3 assistant directors 16th April Therapies and Health Sciences Formal Forum 19th April 2.00pm - 8.00pm Meet the Health Board 5 Executive Directors 28 Event, St Peters Civic Hall, Carmarthen County Director and 3 other members of the Management Team (inc associate medical director) 2 assistant directors 20th April Hywel Dda Partnership Forum, Bronglais 23rd April Band 8+ Focus Group, Withybush 8 24th April 2.00pm - 8.00pm Meet the Health Board 2 Executive Directors 25 Event, Arts Hall, Lampeter County director and 4 other members of Management Team 2 assistant directors 26th April 2.00pm - 8.00pm Meet the Health Board 2 Executive Directors 28 Event, Regency Hall, Saundersfoot 4 County Management Team members (inc associate medical director) 2 assistant directors 27th April Band 8+ Focus Group, Prince Philip 7 30th April Junior Doctors and Middle Grade, 1 Glangwili 30th April Band 8+ Focus Group, Glangwili 3

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Staff Engagement and Communication Activities

7.28 The following information outlines staff communication and engagement activity that has taken place during the listening and engagement phase from December 2011 to the end of April 2012.

Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) All the below are in addition to meetings held locally by managers of specific services with their staff and teams. 19/12/11 Launch of engagement period announced Chair Chief Executive Board Director – Clinical Services Intranet Documents and DVD approx 10,000 live on Intranet and Internet with details on how to feed back Team Brief Team Brief issued approx 10,000 for all staff via Hywel Dda Today global email (for face to face cascade via managers) 03/01/12 Briefing Event – Briefing Event held 50+ Senior Managers for Senior Managers ongoing Chairman’s Blog Ongoing via Intranet No. of Hits: (link issued weekly 1395 Dec via Hywel Dda Today 1478 Jan global email) 1495 Feb 1129 Mar 1314 Apr 09/01/12 Staff Road-show – Presentation, 1 Independent 40+ staff Hafan Derwen question and answer Member session 4 Executive Directors (inc. director of Clinical Services) Therapies and Presentation, 14 Health Sciences question and answer Formal Forum session 11/01/12 Staff Road-show – Presentation, 5 Executive 120+ staff Withybush question and answer Directors (inc 2 session clinical directors) 3 County Management Team (inc 1 senior clinician)

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Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) Medical Staff Presentation, * Committee question and answer (Ceredigion) session 12/01/12 Road-show – Presentation, 5 Executive 110+ staff Bronglais question and answer Directors (inc 1 session clinical director) 5 County Management Team (inc. 3 senior clinicians) 13/01/12 Road-show – Presentation, 4 Executive 80+ staff Glangwili question and answer Directors (inc session clinical director) 6 County Management Team (inc 3 senior clinicians) Road-show – Prince Presentation, 1 Independent 200+ staff Philip question and answer Member session 6 Executive Directors (inc 2 senior clinicians) 6 County Management Team (inc 3 senior clinicians) 16/01/12 Carmarthenshire Presentation, 17 Partnership Forum question and answer session 17/01/12 Culture Steering Presentation, 14 Group question and answer session Three Counties Presentation, 28 Partnership Forum question and answer session 24/01/12 Healthcare Presentation, 10 Professionals Forum question and answer session Tregaron Staff Presentation, 20 Meeting question and answer session 26/01/12 Health Board Chairman’s Update 30+ meeting to Board 02/02/12 Stakeholder Event 36 Reference Group / Health Professional Forum / CAAG

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) 03/02/12 Ceredigion Presentation, * Consultants’ question and answer meeting (Bronglais) session w/c 30/01/12 Team Brief Team Brief issued approx 10,000 staff for all staff via Hywel Dda Today global email (for face to face cascade via managers) w/c 06/02/12 Hywel’s Voice Staff Bilingual staff 2200 hard copy Newsletter newsletter, issued approx 10,000 staff electronically and electronic limited paper versions across sites 17/02/12 Ceredigion Presentation, 40 Consultants’ question and answer Engagement session 17/02/12 Road-show – Prince Additional event 2 Independent 20 Road-show – Philip arranged to Members Prince Philip accommodate staff 3 Executive unable to attend Directors (inc 1 first clinical director) 20 3 County Management Team 21/02/12 HDdHB Partnership Meeting approx 25 Forum w/c 20/02/12 Stakeholder Briefing approx 10,000 Stakeholder issued via email to Briefing wide range of stakeholders, including staff Internet Intranet (staff) Local Media AM/MPs 10+ CHC Members – via 14 CHC PA Stakeholder Reference Group Healthcare Professionals Forum – via Planning PA GP Practice Managers Third Sector contacts – via PPE

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) 20/02/12 Meeting Hywel Dda Partnership Forum, Glangwili 24/02/12 Meeting 60+ Staff Engagement (Bronglais) 28/02/12 Meeting OT Service Leads Meeting, Withybush 29/02/12 Staff Events Cardigan Staff Events (x2 sessions)

05/03/12 Healthcare Meeting 12 Professionals Forum 05/03/12 Focus Group 6 members of staff Staff Focus (band 7) Group (Withybush) 05/03/12 Meeting MSK Outpatients Departments (Llanelli) 06/03/12 Meeting Meeting with OT / Physio Outpatients and MSK Physio Teams from Withybush and South Pembs Hospitals 08/03/12 Meeting Joint Strategy Engagement Sessions with OTs and Physios, Bronglais

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) 12/03/12 Focus Group 4 members of staff Staff Focus (band 7) Group (Glangwili) 15/03/12 Focus Groups Band 7 and under- Staff Focus 9 members of staff Group Band 8+ - 7 (Bronglais) members of staff w/c 19/03/12 Stakeholder Briefing Stakeholder Briefing approx 10,000 issued via email to wide range of stakeholders, including staff Internet Intranet (staff) Local Media AM/MPs 10+ CHC Members – via 14 CHC PA Stakeholder Reference Group Healthcare Professionals Forum – via Planning PA GP Practice Managers Third Sector contacts – via PPE 09/03/12 Meeting Heads of Department Meeting @ Bronglais 22/03/12 Focus Group Focus Group Staff Focus 7 members of staff 7 members of staff Group (Prince (band 7) (band 7) Philip) w/c 19/03/12 Payslip message Payslip message to approx 10,000 all staff w/c 26/03/12 Team Brief Team Brief issued approx 10,000 for all staff via Hywel Dda Today global email (for face to face cascade via managers)

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Staff Engagement and Communication Activity Staff Events/Groups Method(s) Leads (if Reach relevant) w/c 09/04/12 Hywel’s Voice Staff Bilingual staff 2200 hard copy Newsletter newsletter, issued approx 10,000 staff electronically and electronic limited paper versions across sites 20/04/12 Hywel Dda Meeting 24 Partnership Forum, Bronglais w/c 23/04/12 Stakeholder Briefing Stakeholder Briefing approx 10,000 issued via email to wide range of stakeholders, including staff Internet Intranet (staff) Local Media AM/MPs 10+ CHC Members – via 14 CHC PA Stakeholder Reference Group Healthcare Professionals Forum – via Planning PA GP Practice Managers Third Sector contacts – via PPE 23/04/12 Focus Group 8 members of staff Staff Focus (band 8 and above) Group (Withybush) 27/04/12 Focus Group 7 members of staff Staff Focus Group (Prince Philip) 30/04/12 Focus Group 3 members of Staff Focus staff(Band 8 and Group above) (Glangwili) 30/04/12 Focus Group 1 member of staff Staff Focus (medical) Group (Glangwili)

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key Stakeholder Engagement and Communication Activity

7.29 The following information outlines communication and engagement activity that has taken place during the listening and engagement phase from December 2011 to the end of April 2012. Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

AMs Email which included an introduction to the 12 Engagement Process with links to the Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. 1-2-1 meetings with the Chairman Invitations to Meet the Health Board Events Copies of the documents and questionnaires 130 provided for Nia Griffith and Keith Davies Copies of the documents and questionnaires 30 provided for Angela Burns MPs Email which included an introduction to the 5 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. 1-2-1 meetings with Chairman Copies of the documents and questionnaires 130 provided for Nia Griffith and Keith Davies AMs / MPs Email which included an introduction to the 3 (Neighbouring Counties) Engagement Process with links to the Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Copies of the documents and questionnaires 130 provided for Nia Griffith and Keith Davies Invitation to Meet the Health Board events

Air Ambulance Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Community Post. The postal pack contained a letter, 9 Health Councils Discussion Document, Questionnaire and a Poster of the Events. Regular briefings/updates at each of the three Hywel Dda Locality CHC meetings Presentations/discussion at CHC Planning Committee meetings Updates at Health Board Public Board meetings Meet the Health Board Events Stakeholder Reference Group Third Sector Events

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

Detailed correspondence Deanery Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. The Deanery forwarded the email to relevant individuals. GPs Email and Postal Pack sent which included 55 introduction/ introduction letter, Discussion Document, Questionnaire and a Poster of Events. County meetings between Directors and GPs Additional copies of documentation and posters were hand delivered to GP Practices Local Authority (staff) Post. The postal pack contained a letter, 82 discussion Document, Questionnaire and a Poster of the Events. Local Service Boards Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. LMC Email which included an introduction to the 2 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. LMC lead forwarded email to relevant individuals. Neighbouring LHBs Email which included an introduction to the 6 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. The Health Board attended an engagement event at Porthmadog, South Gwynedd The Health Board attended an engagement event at Machynlleth and Llanidloes, Powys Welsh Ambulance Email which included an introduction to the 10 Service Trust Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Represented at Meet the Health Board events

Welsh Health Estates Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. 50+ Forums Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events.

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

Children & Email which included an introduction to the 3 Young People Engagement Process with links to Hywel Dda Partnerships Engagement website, Discussion Document, Questionnaire and a Poster of Events. Follow up email, offering discussions with Clinical Lead for Paediatrics Carers Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events (to Carers Officer in each county). Email inviting comments to the Ceredigion Carer 50 Alliance Circulation List and update regarding events- Email inviting comments and update regarding 37 events to the Carers Group Contacts, Pembrokeshire Presentation to Carmarthenshire Carers - 14

CVCs Email to Directors which included an introduction 3 (CAVS, CAVO to the Engagement Process with links to Hywel & PAVS) Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Guides/Brownies Post. The postal pack contained a letter, 1 Discussion Document, Questionnaire and a Poster of the Events. Colleges & Universities Email which included an introduction to the 6 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Communities First Email which included an introduction to the 9 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Disability Coalition Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Federation of WIs Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Merched y Wawr Post. The postal pack contained a letter, 101 Discussion Document, Questionnaire and a Poster of the Events.

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

Farmers Union Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Health & Social Care Email which included an introduction to the 3 Voluntary Groups Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Third Sector Three Counties Listening Event

Cascading of information by Health Social Care 350+ groups and Wellbeing Facilitators to their existing health and social care networks Carmarthenshire Health Social Care and 16 Wellbeing Forum Pembrokeshire Third Sector Health Social Care and Wellbeing Forum Housing Association Email which included an introduction to the 9 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. League of Friends Post. The postal pack contained a letter, 7 Discussion Document, Questionnaire and a Poster of the Events. Discussion with Cardigan Hospital League of 40 Friends / Cardigan Town Council Meeting Local County Councillors Post. The postal pack contained a letter, 167 Discussion Document, Questionnaire and a Poster of the Events. Presentation to Members at Carmarthenshire 47 County Council Presentation to Members at Ceredigion County 32 Councillors 20 public Council Presentation to Members at Pembrokeshire 30 County Council Menter Iaith Post. The postal pack contained a letter, 5 Discussion Document, Questionnaire and a Poster of the Events. Nursing Homes / Care Post. The postal pack contained a letter, 20 Homes Discussion Document, Questionnaire and a Poster of the Events. Family Centres Post. The postal pack contained a letter, 23 Discussion Document, Questionnaire and a Poster of the Events. Pharmacists Post. The postal pack contained a letter, 103 Discussion Document, Questionnaire and a Poster of the Events.

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

Polish Community Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. St John Ambulance Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Scouts Post. The postal pack contained a letter, 1 Discussion Document, Questionnaire and a Poster of the Events. Siarad Iechyd /Talking Email and Post. Email and Postal Pack sent which 440 Health Members included introduction / introduction letter, Discussion Document, Questionnaire and a Poster of Events. Secondary Schools Email which included an introduction to the 28 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events Transgender Email which included an introduction to the 3 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Town & Community Post. The postal pack contained a letter, 201 Councils Discussion Document, Questionnaire and a Poster of the Events. These were sent to all Town and Community Councils in Carmarthenshire, Ceredigion and Pembrokeshire as well as neighbouring Town and Community Councils in south Gwynedd and north Powys - Presentation to Town and Community 25 Councillors in Carmarthenshire - - Presentation to Town and Community 45 Councillors in Ceredigion - - Presentation to Town and Community 26 Councillors in Pembrokeshire - Voluntary Organisations Email / Post which included an introduction to the 26 providing services under Engagement Process with links to Hywel Dda SLAs Engagement website, Discussion Document, Questionnaire and a Poster of Events. Women’s Aid Post. The postal pack contained a letter, 5 Discussion Document, Questionnaire and a Poster of the Events Coast Guard Post. The postal pack contained a letter, 1 Discussion Document, Questionnaire and a Poster of the Events.

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Key stakeholder engagement and communication activity

Stakeholder Method(s) Reach

General Public Distribution of the Case for Change pamphlet and 180,000 households DVD to all households across the three counties were targeted. and neighbouring areas who access health services from Hywel Dda Health Board, Discussion documents available on –line. Hits to Over 7,000 the home page for Your Health Your Future Hard copies of the documents available at Libraries, GP surgeries etc 12 Meet the Health Board Events across the three 1,214 counties 7 Public focus groups - 76 Completion of the online questionnaire - Interim total - 736 Completion of postal questionnaires - Interim total - 285 Dentists Post. The postal pack contained a letter, 52 Discussion Document, Questionnaire and a Poster of the Events. Fire Brigade Service Email which included an introduction to the 1 Engagement Process with links to Hywel Dda Engagement website, Discussion Document, Questionnaire and a Poster of Events. Libraries Post. The postal pack contained a letter, 41 Discussion Document, Questionnaire and a Poster of the Events. Opticians Post. The postal pack contained a letter, 64 Discussion Document, Questionnaire and a Poster of the Events. Police Email. The postal pack contained a letter, 1 Discussion Document, Questionnaire and a Poster of the Events. RNLI Post. The postal pack contained a letter, 4 Discussion Document, Questionnaire and a Poster of the Events. Refineries Email. The postal pack contained a letter, 2 Discussion Document, Questionnaire and a Poster of the Events. Steel Works Email . The postal pack contained a letter, 1 Discussion Document, Questionnaire and a Poster of the Events.

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Political Engagement Events and Key Meetings

Political Engagement activity Date Attendees 5 Apr 11 St David’s Town Council Cllr Glenis James Mrs Pat Goddard Cllr Stephanie Halse Cllr Christopher Taylor 23 May 11 Tenby Town Council Cllr Caroline Thomas Cllr Lawrence Blackhall Julie Evans 20 Jun 11 Neyland Town Council Town Clerk Cllr Jonathan Llewellyn Mrs Margaret Brace Cllr Wilson 20 Jun 11 Pembroke Town Council Cllr Christine Gwyther Cllr Andrew McNaughton Moira Saunders Town Clerk 17 Aug 11 Keith Davies AM Nia Griffiths MP 5 Sep 11 Elin Jones, AM 10 Oct 11 Angela Burns AM Paul Davies AM 10 Oct 11 Joyce Watson AM 24 Oct 11 Elin Jones AM 7 Nov 11 Keith Davies AM 7 Nov 11 Fishguard & Goodwick Town Council Cllr. Mrs M Stringer (Deputy Mayor) Cllr Owen James Cllr Richard Grosvenor Cllr Bob Wheatley 14 Nov 11 Rhodri Glyn Thomas AM 14 Nov 11 Simon Thomas AM 25 Nov 11 Simon Hart MP 14 Dec 11 Mark Williams MP 9 Jan 12 Angela Burns AM Paul Davies AM 25 Jan 12 SOSPPAN Deryk Cundy Bryan Hitchman Tony Flatley 7 Feb 12 SWAT Dr Overton Dr Milewski 26 Mar 12 Paul Davies AM Angela Burns AM

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Political Engagement activity Date Attendees 30 Mar 12 Board of Aber Group (including Elin Jones AM) 30 Mar 12 Elin Jones AM 2 Apr 12 Kirsty Williams AM William Powell AM 30 Apr 12 Joyce Watson AM 1 May 12 SOSPPAN Derek Cundy Brian Hitchman Louvain Roberts Tony Flatley Haydn Jones 2 May 12 Maria Battle AM

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Details of media activity

7.30 The following information outlines the extent of media activity that has taken place during the Listening and Engagement phase (December 2011 to the end of April 2012). Please note:

Key: GOLD proactive press releases and broadcast interviews provided by the Health Board

CLEAR coverage in print media

Reach figures are based on average audience/reader figures where they are available and are detailed in their first mention only in the table below. It is not possible to provide a total figure as audiences may cross media outlets. However, these figures demonstrate that information about the listening and engagement exercise have potentially reached a very large proportion of our total population (180,000).

Media Activity & Reach Date Activity Estimated Reach 19.12.11 Media launch - press release and supporting documentation sent to all media contacts (local, regional and national media). Interviews taken up by: Western Telegraph, Cambrian News, Carmarthen Journal/Llanelli Star/South Wales Evening Post, Western Mail. Interview spokesperson provided to BBC for on-camera interviews. Resulting coverage captured below. 20.12.11 – Interview (Phil Kloer) with BBC 1 Wales Today (English 273,000 television news) and S4C Newyddion (Welsh news) (Average audience Wales Today BARB 2010/11) 18,000 (Average audience Neywddion ACW 2010/11) 21.12.11 Western Telegraph 19,582  2 articles (front page) (ABC readership July-Dec 2011) 21.12.11 Llanelli Star 12,996  3 articles (front page + editorial comment) (ABC readership July-Dec 2011) 21.12.11 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 21.12.11 Carmarthen Journal 16,408  1 article (ABC readership July-Dec 2011) 21.12.11 Interview (Linda Williams) with Radio Cymru for news 153,000 through the day (Radio Cymru average weekly reach RAJAR 2011) 22.12.11 Western Mail 25,898  1 article (ABC readership July-Dec 2011) 22.12.11 Cambrian News 63,000  4 articles (page spread) (Papers own figures) 22.12.11 Milford Mercury 3,515  1 article (front page) (ABC readership July-Dec 2011) 27.12.11 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 27.12.11 Tivyside Advertiser 6,719  1 article (ABC readership July-Dec 2011)

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Media Activity & Reach Date Activity Estimated Reach 28.12.11 Carmarthen Journal 16,408  4 article, (page spread and editorial comment) (ABC readership July-Dec 2011) 29.12.11 Cambrian News 63,000  3 articles (Papers own figures) 30.12.11 Tenby Observer 8,000  1 article (Papers own figures) January Interview Nicola O’Sullivan with Town and County 278,000 (17 per cent) Broadcasting (Radio Carmarthenshire, Ceredigion, (Average audience RAJAR) Pembrokeshire, Scarlet FM) 04.01.12 Western Telegraph 19,582  1 article (front page) (ABC readership July-Dec 2011) 05.01.12 Cambrian News 63,000  4 articles (Papers own figures) 11.01.12 Llanelli Star 12,996  8 articles (page spread and editorial comment) (ABC readership July-Dec 2011) 11.01.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 12.01.12 Cambrian News 63,000  7 articles (page spread and editorial comment) (Papers own figures) 13.01.12 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 16.01.12 Live broadcast from Glangwili Hospital with Radio Cymru 40,000 Post Cyntaf programme (Post Cyntaf average audience ACW 2010/11) 17.01.12 Press release x 3 county versions - Health event dates reminder

18.01.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 18.01.12 Llanelli Star 12,996  12 articles (front page, double page spread, (ABC readership July-Dec 2011) editorial) 19.01.12 Cambrian News 63,000  5 articles (page spread, editorial comment) (Papers own figures) 19.01.12 Interview (Mr Jeremy Williams) with ITV Wales Tonight 148,000 (Average audience Wales Tonight ITV Media 2010) 20.01.12 Press release – Doctors come to a living room near you (DVD)

24.01.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 24.01.12 Tivyside Advertiser 6,719  ADVERT meet the health board (ABC readership July-Dec 2011) 25.01.12 Llanelli Star 12,996  11 articles (front page, page spread, editorial) (ABC readership July-Dec 2011) 25.01.12 Western Telegraph 19,582  3 article (ABC readership July-Dec 2011)  ADVERT meet the health board

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Media Activity & Reach Date Activity Estimated Reach 26.01.12 Milford Mercury 3,515  ADVERT meet the health board (ABC readership July-Dec 2011)

27.01.12 Tenby Observer 8,000  1 article (Papers own figures) 31.01.12 Tivyside Advertiser 6,719  2 articles (ABC readership July-Dec 2011) 01.02.12 Carmarthen Journal 16,408  ADVERT meet the health board (ABC readership July-Dec 2011)  1 article (comment) 01.02.12 Llanelli Star 12,996  ADVERT meet the health board (ABC readership July-Dec 2011)

01.02.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011)  ADVERT meet the health board 02.02 Statement for broadcast programme on Sharp End ITV Figures not available

02.02 Interview (Tony Chambers) for BBC 1 Wales Today and ITV 273,000 Wales Tonight (Average audience Wales Today BARB 2010/11) 148,000 (Average audience Wales Tonight ITV Media 2010)

02.02.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 02.02.12 Cambrian News 63,000  8 articles (page spread, comment, editorial) (Papers own figures)  ADVERT meet the health board 06.02.12 Interview with spokespersons (Linda Williams, John 153,000 Edwards, Duncan Williams, Carys Morgan) for Radio (Radio Cymru average weekly reach RAJAR 2011) Cymru Manylu 06.02 Statement to S4C Yr Bed a Bedwar Figures not available

07.02.12 Press release – Meet the Health Board events

07.02.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 08.02.12 Llanelli Star 12,996  12 article (front page, editorial comment) (ABC readership July-Dec 2011)

09.02.12 Cambrian News 63,000  8 articles (front page, comment) (Papers own figures) 09.02.12 South Wales Evening Post 38,364 1 article (ABC readership July-Dec 2011) 10.02.12 Press release – Listening and engagement continues (lobby groups, council meetings) issued to media

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Media Activity & Reach Date Activity Estimated Reach 10.02.12 Interview (Tony Chambers) ITV Wales Tonight 148,000 (Average audience Wales Tonight ITV Media 2010) 10.02.12 Letter to Editor from AMD to Llanelli Star

10.02.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 10.02.12 Tenby Observer 8,000  1 article (Papers own figures) 13.02.12 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 13.02.12 Letter to Editor x 2 from Chairman to Tivyside, Western Telegraph

15.02.12 Llanelli Star 12,996  9 articles (page spread, editorial comment) (ABC readership July-Dec 2011) 15.02.12 Western Telegraph 19,582  6 articles (front, editorial) (ABC readership July-Dec 2011) 16.02.12 Interview (Trevor Purt) with BBC 1 Wales Today and S4C 273,000 Newyddion (Average audience Wales Today BARB 2010/11) 18,000 (Average audience Neywddion ACW 2010/11) 16.02.12 Cambrian News 63,000  10 articles (double page spread) (Papers own figures) 17.02.12 Letter to Editor x 5from Chairman to Llanelli Star/Carmarthen Journal/Evening Post, Ammanford Guardian, Cambrian News 17.02.12 Letter to Editor from Medical Director to Cambrian News

18.02.12 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 20.02.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 21.02.12 South Wales Evening Post 38,364  2 article (ABC readership July-Dec 2011) 21.02.12 Tivyside Advertiser 6,719  Letter from Chairman of Hywel Dda Health Board (ABC readership July-Dec 2011)  1 article 22.02.12 Clinical Services Strategy Stakeholder Briefing sent to all media contacts

22.02.12 Carmarthen Journal 16,408  Letter from Chairman of Hywel Dda Health Board (ABC readership July-Dec 2011) 22.02.12 Llanelli Star 12,996  11 articles (double page spread) (ABC readership July-Dec 2011) 22.02.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011)  Letter from Chairman of Hywel Dda Health Board 23.02.12 Western Mail 25,898  1 article (ABC readership July-Dec 2011)

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Media Activity & Reach Date Activity Estimated Reach 23.02.12 Cambrian News 63,000  4 articles (page spread, editorial) (Papers own figures)  Letter from Medical Director of Hywel Dda Health Board 24.02.12 Press releases – Llanelli voices are being heard

27.02.12 Press release – Becoming a wellness service (Ceredigion ART team)

28.02.12 Tivyside Advertiser 6,719  3 articles (ABC readership July-Dec 2011) 29.02.12 Interview (Kathryn Davies) for Radio Wales phone-in and 468,000 news and BBC 1 Wales Today (Radio Wales weekly reach of RAJAR 2011) 29.02.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 29.02.12 Llanelli Star 12,996  11 articles (front page, page spread, editorial) (ABC readership July-Dec 2011) 01.03.12 Cambrian News 63,000  11 articles (front page, double page spread, (Papers own figures) editorial, comment) 02.03.12 Press release – Health Board will listen for longer

02.03.12 South Wales Evening Post 38,364  1 article (front page) (ABC readership July-Dec 2011) 03.03.12 Western Mail 25,898  1 article (ABC readership July-Dec 2011) 05.03.12 Press release x 2 – Becoming a wellness service (Carmarthenshire and Pembrokeshire ART case study) 06.03.12 Western Mail 25,898  1 article (ABC readership July-Dec 2011) 07.03.12 Llanelli Star 12,996  14 articles (double page spread, editorial, (ABC readership July-Dec 2011) comment) 08.03.12 South Wales Evening Post 38,364  1 article (front) (ABC readership July-Dec 2011)

08.03.12 Cambrian News 63,000  9 articles (front, double page spread, editorial) (Papers own figures) 09.03.12 South Wales Evening Post 38,364  1 article (front) (ABC readership July-Dec 2011) 14.03.12 Western Telegraph 19,582  2 articles (ABC readership July-Dec 2011) 14.03.12 Carmarthen Journal 16,408  1 article (ABC readership July-Dec 2011) 14.03.12 Llanelli Star 12,996  11 articles (front, double page spread, editorial) (ABC readership July-Dec 2011) 16.03.12 Press release – State of the heart new treatment (PPCI demonstrating value of specialist services)

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Opinion Research Services Hywel Dda Health Board’s Listening and Engagement Process – Report of Findings July 2012

Media Activity & Reach Date Activity Estimated Reach 17.03.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 19.03.12 Press release – New Meet the Health Board event dates announced

19.03.12 Press release – Road testing improvements for non-emergency transport

20.03.12 Tivyside Advertiser 6,719  1 article (ABC readership July-Dec 2011) 21.03.12 Llanelli Star 12,996  6 articles (page spread, editorial) (ABC readership July-Dec 2011) 21.03.12 Western Telegraph 19,582  3 articles (ABC readership July-Dec 2011) 23.03.12 Press release – Caring for sick and premature babies

28.03.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 28.03.12 Llanelli Star 12,996  9 articles (front page, page spread, editorial) (ABC readership July-Dec 2011) 29.03.12 Milford Mercury 3,515  1 article (ABC readership July-Dec 2011) 29.03.12 Cambrian News 63,000  6 articles (double page spread) (Papers own figures) 30.03.12 Clinical Services Strategy Stakeholder briefing sent to media contacts

30.03.12 Interview (Iain Robertson steel) for BBC 1 Wales Today

30.03.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 30.03.12 Western Mail 25,898  1 article (ABC readership July-Dec 2011) 03.04.12 Press release – Health Board ambition for Bronglais as regional centre

04.04.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011)  ADVERT meet the health board 04.04.12 Llanelli Star 12,996  7 articles (front page, page spread, editorial) (ABC readership July-Dec 2011)  ADVERT meet the health board 04.04.12 Carmarthen Journal 16,408  ADVERT meet the health board (ABC readership July-Dec 2011) 04.04.12 South Wales Evening Post 38,364  ADVERT meet the health board (ABC readership July-Dec 2011) 04.04.12 Press release – Case for change leaflet and DVD

05.04.12 Cambrian News 63,000  3 articles (Papers own figures)  ADVERT meet the health board 06.04.12 Tenby Observer 8,000  ADVERT meet the health board (Papers own figures)

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Media Activity & Reach Date Activity Estimated Reach 09.04.12 Ammanford Guardian 5,837  ADVERT meet the health board (ABC readership July-Dec 2011) 10.04.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 11.04.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 11.04 Llanelli Star 12,996  5 articles (page spread) (ABC readership July-Dec 2011) 19.04.12 Milford Mercury 3,515  1 article (ABC readership July-Dec 2011) 23.04.12 Press release – Final call to Meet the Health Board

23.04.12 Interview with Town and County Broadcasting (Delyth 278,000 (17 per cent) Evans) (Average audience RAJAR) 25.04.12 Llanelli Star 12,996  5 articles (ABC readership July-Dec 2011) 25.04.12 South Wales Evening Post 38,364  1 article (ABC readership July-Dec 2011) 25.04.12 Western Telegraph 19,582  1 article (ABC readership July-Dec 2011) 27.04.12 Clinical Services Strategy Stakeholder briefing sent to all media contacts.

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Distribution List – Paper Copies

Paper Copies of the Discussion Document and Questionnaires sent to the following across Carmarthenshire, Ceredigion and Pembrokeshire.

50+ Forum Representatives Carmarthenshire County Council (Executives, Heads of Departments and Managers) Ceredigion County Council (Executives, Head of Departments and Managers) Community Health Councils Coastguard Community Hospitals County Councillors Dentists Family Centres Farmers Unions GPs GP Practices Guides and Brownies Health Centres Hospitals – Bronglais, Glangwili, Prince Philip and Withybush League of Friends Libraries Local Medical Committee Mental Health & Learning Disabilities Centres Neighbouring Health Boards Nursing/Care Homes Opticians Pembrokeshire County Council (Executives, Heads of Departments and Managers) Pharmacists RNLI Scout Association Town and Community Councils Women’s Institutes

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Distribution List - Electronic copies of the Discussion Document and Questionnaires sent to the following across Carmarthenshire, Ceredigion and Pembrokeshire:

BME Communities (three counties) Carmarthenshire Association of Voluntary Services (CAVS) Carmarthenshire Disability Coalition for Action Ceredigion Association of Voluntary Organisations (CAVO) Colleges Communities First Dyfed-Powys Police Health & Social Care Voluntary Groups Housing Associations Llanelli Multicultural Network Local Service Boards Menter Cwm Gwendraeth Mid & West Wales Fire Rescue Service Oil Refineries Pembrokeshire Association of Voluntary Services (PAVS) Polish Welsh Association Politicians (AMs, Regional AMs and MPs) Practice Managers Secondary Schools Siarad Iechyd/Talking Health Members St John's Ambulance Support Groups Trans-G.I.S.T. (three counties) The Deanery Universities Wales Air Ambulance Welsh Ambulance Service Trust Welsh Health Estates Young Farmers

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